Australian Dental Journal
The official journal of the Australian Dental Association
Australian Dental Journal 2014; 59: 321–328 doi: 10.1111/adj.12188
Dental caries in Victorian nursing homes M Silva,* M Hopcraft,* M Morgan* *Melbourne Dental School, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Victoria.
ABSTRACT Background: The poor oral health of nursing home residents is the cause of substantial morbidity and has major implications relating to health care policy. The aim of this study was to measure dental caries experience in Australians living in nursing homes, and investigate associations with resident characteristics. Methods: Clinical dental examinations were conducted on 243 residents from 19 nursing homes in Melbourne. Resident characteristics were obtained from nursing home records and interviews with residents, family and nursing home staff. Two dental examiners assessed coronal and root dental caries using standard ICDAS-II criteria. Results: Residents were elderly, medically compromised and functionally impaired. Most required assistance with oral hygiene and professional dental care was rarely utilized. Residents had high rates of coronal and root caries, with a mean 2.8 teeth with untreated coronal caries and 5.0 root surfaces with untreated root caries. Functional impairment and irregular professional dental care were associated with higher rates of untreated tooth decay. There were no significant associations with medical conditions or the number of medications taken. Conclusions: Nursing home residents have high levels of untreated coronal and root caries, particularly those with high needs due to functional impairment but poor access to professional services. Keywords: Dementia, dental caries, elderly, nursing home, root caries. Abbreviations and acronyms: ADL = Activities of Daily Living Index; DFRS = Decayed, Filled, Root Surfaces; DMFT = Decayed, Missing, Filled Teeth; DRS = Decayed Root Surfaces; DT = Decayed Teeth; FT = Filled Teeth; ICDAS II = International Caries Detection and Assessment System; PCC = pensioner concession cards; PHI = private health insurance; RCI = Root Caries Index. (Accepted for publication 8 October 2013.)
INTRODUCTION As in the rest of the developing world, the Australian population is ageing, with the proportion and absolute numbers of adults aged 65 years and over projected to increase dramatically over the next 50 years.1 As a consequence, more older Australians are living in nursing homes.2 The picture of oral health in nursing homes is increasingly characterized by patients having natural teeth with complex restorations and partial prostheses.3 However, increased retention of teeth in this population is also associated with a concomitant rise in the prevalence of dental diseases, as demonstrated in several Australian and international studies, which have consistently shown high levels of plaque, gingivitis and untreated dental caries.4–9 The impact of poor oral health extends beyond the mouth, and can affect the general health of residents and impair quality of life.10–14 There is a growing body of evidence supporting the existence of common risk factors for oral and systemic diseases, including cardiovascular disease, diabetes, stroke and aspiration © 2014 Australian Dental Association
pneumonia. The latter is the leading cause of death among nursing home residents and is associated with significant morbidity and cost to the health care systems of many countries.15 The reasons for the poor oral health of nursing home residents may be multifactorial. Physical and cognitive impairment makes oral hygiene difficult, making residents increasingly dependent on other people and often resulting in poor oral cleanliness.5,16,17 In addition, dental treatment provision to nursing home residents tends to be emergency-based, with little time spent on prevention, especially among vulnerable residents with cognitive and physical impairment.6,18,19 In 2002, Chalmers et al. reported that oral health often deteriorates prior to admission into residential care, resulting in an increased burden of disease at entry.20 Further issues such as salivary disease, medications and cariogenic diets, may also exacerbate pre-exisiting dental problems.7,21,22 The potent combination of these risk factors allow simple oral and dental problems to deteriorate rapidly, becoming more complex and leading to emergency dental treatment. 321
M Silva et al. The aim of this study was to measure dental caries experience in Australians living in nursing homes, and investigate associations with demographic and resident factors that may enable the delivery of targeted interventions. MATERIALS AND METHODS This project had ethics approval from The University of Melbourne Human Research Ethics Committee. Nineteen high care nursing homes in metropolitan Melbourne with 30–60 residents were selected from a list of facilities obtained from the Commonwealth Department of Health and Ageing website.23 The list was randomly sorted, and facilities were contacted to participate until 19 agreed. All residents, including those with cognitive impairment and in palliative care, were invited to participate in the study. Informed consent was obtained from all participants or when necessary, from legal guardians. Residents’ nursing home records and medication charts were assessed to obtain demographic details such as age and date of admission and medical and dental history, including medical diagnoses and medications as well as any details of past dental treatment. Where possible, this was supplemented with a brief interview of the residents. When cognitive impairment or language problems made this difficult, family members or nursing home staff assistance was accepted. An Activities of Daily Living (ADL) index was calculated for each resident by nursing home staff.24 Residents’ impairment was rated as severe if they were able to complete less than three basic activities independently, moderate if they were able to complete three or four and minor if they were able to complete five or all six. The dental examinations were conducted by two trained and calibrated dentists using a disposable, illuminated mouth mirror (DenLite, Welch Allyn Ltd, Navan, Co Meath, Ireland), periodontal probe and sickle probe, with additional lighting provided by a headlamp. Where necessary, toothbrushes were used to remove plaque deposits and allow visualization of tooth surfaces. However, calculus deposits were not removed. Coronal and root dental caries were recorded using the International Caries Detection and Assessment System (ICDAS II),25 which was then converted to the Decayed, Missing, Filled Teeth (DMFT) and Decayed, Filled, Root Surfaces (DFRS) indices for ease of analysis. ICDAS II coronal caries codes 4, 5 and 6 were classified as decayed teeth. ICDAS II caries codes 1, 2 and 3 were classified as sound teeth. ICDAS II root caries code 1 was classified as noncavitated root caries and code 2 as cavitated root caries. Surfaces that could not be visualized were excluded. Both cavitated and non-cavitated root caries 322
lesions were included in calculation of the Root Caries Index (RCI), the proportion of exposed root surfaces with decay. The examinations were conducted in a variety of locations within the nursing home, including in residents’ beds, wheelchairs or sitting in a regular chair, depending on the physical capacity of the resident. Standard infection control procedures were followed, including the use of gloves, facemasks and safety glasses. No radiographs were taken. If residents were unable to be examined at the initial visit due to behavioural problems, examinations were attempted at a subsequent visit, with a range of specialized behavioural and communication strategies that have been specifically developed for patients with dementia. All data were initially entered into a spreadsheet (Microsoft Excel for Mac 2011, Microsoft Corp, Redmond, Washington, USA) and transferred to SPSS (SPSS 17.0, Chicago, IL, USA) for analysis. Descriptive statistics were used to describe the study sample, with comparisons using chi-squared tests. Significance was set at a level of p < 0.05. Differences in the mean number of teeth present and caries experience measures, including DMFT, decayed teeth (DT), filled teeth (FT), decayed root surfaces (DRS) (all lesions and cavitated lesions only), DFRS and RCI were assessed using one-way analysis of variance, with significance level set to p < 0.05. The weighted kappa score for inter-examiner reliability was 0.82. RESULTS Resident characteristics and past dental history The study involved residents and staff from 19 nursing homes catering to high care residents in metropolitan Melbourne. For some subjects with high levels of cognitive impairment, complete data were not obtained. Participation rates for residents varied from 38.3% to 90% across the facilities. Of the residents examined at the nursing homes, 30% to 87.5% were dentate resulting in a total of 243 residents who were able to participate in the study. No information was available about non-participants. Details regarding resident characteristics are provided in Table 1. Nursing home residents participating in this study were elderly with a mean age of 83 years, and a range of 46 to 102 years. There were more females, 163 (67.1%) than males, 80 (32.9%) in the study sample. Male participants were significantly younger than their female counterparts (p < 0.001, v2 = 22.17). While most were eligible for pensioner concession cards (PCC), only about a third of residents had private health insurance (PHI). © 2014 Australian Dental Association
Dental caries in Victorian nursing homes Table 1. Resident characteristics and past dental history (%)
The official journal of the Australian Dental Association
Australian Dental Journal 2014; 59: 321–328 doi: 10.1111/adj.12188
Dental caries in Victorian nursing homes M Silva,* M Hopcraft,* M Morgan* *Melbourne Dental School, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Victoria.
ABSTRACT Background: The poor oral health of nursing home residents is the cause of substantial morbidity and has major implications relating to health care policy. The aim of this study was to measure dental caries experience in Australians living in nursing homes, and investigate associations with resident characteristics. Methods: Clinical dental examinations were conducted on 243 residents from 19 nursing homes in Melbourne. Resident characteristics were obtained from nursing home records and interviews with residents, family and nursing home staff. Two dental examiners assessed coronal and root dental caries using standard ICDAS-II criteria. Results: Residents were elderly, medically compromised and functionally impaired. Most required assistance with oral hygiene and professional dental care was rarely utilized. Residents had high rates of coronal and root caries, with a mean 2.8 teeth with untreated coronal caries and 5.0 root surfaces with untreated root caries. Functional impairment and irregular professional dental care were associated with higher rates of untreated tooth decay. There were no significant associations with medical conditions or the number of medications taken. Conclusions: Nursing home residents have high levels of untreated coronal and root caries, particularly those with high needs due to functional impairment but poor access to professional services. Keywords: Dementia, dental caries, elderly, nursing home, root caries. Abbreviations and acronyms: ADL = Activities of Daily Living Index; DFRS = Decayed, Filled, Root Surfaces; DMFT = Decayed, Missing, Filled Teeth; DRS = Decayed Root Surfaces; DT = Decayed Teeth; FT = Filled Teeth; ICDAS II = International Caries Detection and Assessment System; PCC = pensioner concession cards; PHI = private health insurance; RCI = Root Caries Index. (Accepted for publication 8 October 2013.)
INTRODUCTION As in the rest of the developing world, the Australian population is ageing, with the proportion and absolute numbers of adults aged 65 years and over projected to increase dramatically over the next 50 years.1 As a consequence, more older Australians are living in nursing homes.2 The picture of oral health in nursing homes is increasingly characterized by patients having natural teeth with complex restorations and partial prostheses.3 However, increased retention of teeth in this population is also associated with a concomitant rise in the prevalence of dental diseases, as demonstrated in several Australian and international studies, which have consistently shown high levels of plaque, gingivitis and untreated dental caries.4–9 The impact of poor oral health extends beyond the mouth, and can affect the general health of residents and impair quality of life.10–14 There is a growing body of evidence supporting the existence of common risk factors for oral and systemic diseases, including cardiovascular disease, diabetes, stroke and aspiration © 2014 Australian Dental Association
pneumonia. The latter is the leading cause of death among nursing home residents and is associated with significant morbidity and cost to the health care systems of many countries.15 The reasons for the poor oral health of nursing home residents may be multifactorial. Physical and cognitive impairment makes oral hygiene difficult, making residents increasingly dependent on other people and often resulting in poor oral cleanliness.5,16,17 In addition, dental treatment provision to nursing home residents tends to be emergency-based, with little time spent on prevention, especially among vulnerable residents with cognitive and physical impairment.6,18,19 In 2002, Chalmers et al. reported that oral health often deteriorates prior to admission into residential care, resulting in an increased burden of disease at entry.20 Further issues such as salivary disease, medications and cariogenic diets, may also exacerbate pre-exisiting dental problems.7,21,22 The potent combination of these risk factors allow simple oral and dental problems to deteriorate rapidly, becoming more complex and leading to emergency dental treatment. 321
M Silva et al. The aim of this study was to measure dental caries experience in Australians living in nursing homes, and investigate associations with demographic and resident factors that may enable the delivery of targeted interventions. MATERIALS AND METHODS This project had ethics approval from The University of Melbourne Human Research Ethics Committee. Nineteen high care nursing homes in metropolitan Melbourne with 30–60 residents were selected from a list of facilities obtained from the Commonwealth Department of Health and Ageing website.23 The list was randomly sorted, and facilities were contacted to participate until 19 agreed. All residents, including those with cognitive impairment and in palliative care, were invited to participate in the study. Informed consent was obtained from all participants or when necessary, from legal guardians. Residents’ nursing home records and medication charts were assessed to obtain demographic details such as age and date of admission and medical and dental history, including medical diagnoses and medications as well as any details of past dental treatment. Where possible, this was supplemented with a brief interview of the residents. When cognitive impairment or language problems made this difficult, family members or nursing home staff assistance was accepted. An Activities of Daily Living (ADL) index was calculated for each resident by nursing home staff.24 Residents’ impairment was rated as severe if they were able to complete less than three basic activities independently, moderate if they were able to complete three or four and minor if they were able to complete five or all six. The dental examinations were conducted by two trained and calibrated dentists using a disposable, illuminated mouth mirror (DenLite, Welch Allyn Ltd, Navan, Co Meath, Ireland), periodontal probe and sickle probe, with additional lighting provided by a headlamp. Where necessary, toothbrushes were used to remove plaque deposits and allow visualization of tooth surfaces. However, calculus deposits were not removed. Coronal and root dental caries were recorded using the International Caries Detection and Assessment System (ICDAS II),25 which was then converted to the Decayed, Missing, Filled Teeth (DMFT) and Decayed, Filled, Root Surfaces (DFRS) indices for ease of analysis. ICDAS II coronal caries codes 4, 5 and 6 were classified as decayed teeth. ICDAS II caries codes 1, 2 and 3 were classified as sound teeth. ICDAS II root caries code 1 was classified as noncavitated root caries and code 2 as cavitated root caries. Surfaces that could not be visualized were excluded. Both cavitated and non-cavitated root caries 322
lesions were included in calculation of the Root Caries Index (RCI), the proportion of exposed root surfaces with decay. The examinations were conducted in a variety of locations within the nursing home, including in residents’ beds, wheelchairs or sitting in a regular chair, depending on the physical capacity of the resident. Standard infection control procedures were followed, including the use of gloves, facemasks and safety glasses. No radiographs were taken. If residents were unable to be examined at the initial visit due to behavioural problems, examinations were attempted at a subsequent visit, with a range of specialized behavioural and communication strategies that have been specifically developed for patients with dementia. All data were initially entered into a spreadsheet (Microsoft Excel for Mac 2011, Microsoft Corp, Redmond, Washington, USA) and transferred to SPSS (SPSS 17.0, Chicago, IL, USA) for analysis. Descriptive statistics were used to describe the study sample, with comparisons using chi-squared tests. Significance was set at a level of p < 0.05. Differences in the mean number of teeth present and caries experience measures, including DMFT, decayed teeth (DT), filled teeth (FT), decayed root surfaces (DRS) (all lesions and cavitated lesions only), DFRS and RCI were assessed using one-way analysis of variance, with significance level set to p < 0.05. The weighted kappa score for inter-examiner reliability was 0.82. RESULTS Resident characteristics and past dental history The study involved residents and staff from 19 nursing homes catering to high care residents in metropolitan Melbourne. For some subjects with high levels of cognitive impairment, complete data were not obtained. Participation rates for residents varied from 38.3% to 90% across the facilities. Of the residents examined at the nursing homes, 30% to 87.5% were dentate resulting in a total of 243 residents who were able to participate in the study. No information was available about non-participants. Details regarding resident characteristics are provided in Table 1. Nursing home residents participating in this study were elderly with a mean age of 83 years, and a range of 46 to 102 years. There were more females, 163 (67.1%) than males, 80 (32.9%) in the study sample. Male participants were significantly younger than their female counterparts (p < 0.001, v2 = 22.17). While most were eligible for pensioner concession cards (PCC), only about a third of residents had private health insurance (PHI). © 2014 Australian Dental Association
Dental caries in Victorian nursing homes Table 1. Resident characteristics and past dental history (%)
