DIAGNOSIS/TREATMENT/PROGNOSIS
ARTICLE ANALYSIS & EVALUATION ARTICLE TITLE AND BIBLIOGRAPHIC INFORMATION Long-term routine dental attendance: influence on tooth loss and oral health-related quality of life in Swedish older adults. Astrøm AN, Ekback G, Ordell S, Nasir E. Community Dent Oral Epidemiol 2014;42(5):460-69.
Long-term Routine Dental Attendance is Important for Older Adults SUMMARY Subjects Subjects were persons born in 1942 residing in two counties in Sweden. The sample size was 4143 at follow-up (response rate 65%) after 5, 10, and 15 years. The birth cohort was age 50 to 65 years at the time of the four longitudinal surveys (1992, 1997, 2000, and 2007) and close to evenly split between genders (50.2% female).
REVIEWER Leonard A. Crocombe, BDSc, MBA, MPA, PhD
PURPOSE/QUESTION To investigate the effect of longterm dental attendance on oral health-n-related quality of life and tooth loss.
Key Exposure/Study Factor Long-term dental attendance was measured by asking the participants at each step of the longitudinal survey when their last dental visit was and who (dentist or self) or what was the initiative (check-up or problem) for the last dental visit. Routine dental attendance was defined as attendance within the preceding 12 months or in response to personal decision for regular check-ups. Non-routine dental attendance was defined as attendance less frequently than within the previous 12 months or in response to dental problems or pain. Long-term routine dental attendance was defined as routine dental attendance in both 1992 and 2007.
SOURCE OF FUNDING
Main Outcome Measure
Government: Department of Dentistry, Orebro County; The Dental Commissioning Unit, Ostergotland County, Sweden; NRC Grant 204887/V50.
Major tooth loss defined as participant-reported dentition status of missing many teeth or being edentulous. Oral health-n-related quality of life was measured by the eight-item impact of daily performance inventory (OIDP) obtained at the final (2007) survey only. This measure asked about difficulties with eating and enjoying food, speaking and pronouncing clearly, tooth cleaning, sleep and relaxation, smiling and showing teeth without being embarrassed, being emotionally stable, being sociable, and performing daily activities.
TYPE OF STUDY/DESIGN Cohort study
LEVEL OF EVIDENCE Level 2: Limited-quality, patientoriented evidence
STRENGTH OF RECOMMENDATION GRADE Not applicable
Main Results Adjusted logistic regression revealed that individuals reporting long-term routine dental attendance were 0.3 (95% confidence interval [CI]: 0.2–0.5) times less likely than non-routine attenders to report oral impacts. Generalized estimating equations indicated long-term routine dental attenders were 0.6 (95% CI: 0.4–0.7) times less likely than non-routine attenders to report major tooth loss.
Conclusions Compared with long-term non-regular dental attendance, long-term routine dental attendance was associated with lower major tooth loss and better oral health-n-related quality of life.
COMMENTARY AND ANALYSIS J Evid Base Dent Pract 2015;15:39-40 1532-3382/$36.00 Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jebdp.2015.01.003
This study shows the importance of long-term dental attendance for clinical oral health and oral health-n-related quality of life in individuals age 50 to 65 years. The study’s strengths are its large sample size, the statistical
JOURNAL OF EVIDENCE-BASED DENTAL PRACTICE
analysis that incorporated social demographic variables and sociobehavioral factors, and the fact that it is a longitudinal study. This last fact suggests that because the longterm dental attendance preceded the clinical oral health and oral health-n-related quality of life outcomes, the association between the independent and dependent variables may be causal. The study also showed that routine dental attendance decreased as people approached retirement age. This is of particular importance in a rapidly aging population and when we know that eating textured and nutritious foods becomes challenging in older adults and adults are at risk for inadequate nutrition, dehydration, and declining health.1–8 If older adults have poor oral hygiene and aspirate food or liquid into the lungs after swallowing, they are at risk for developing aspiration pneumonia.9 Other medical complications related to poor oral health include gastrointestinal dysfunction, cognitive decline, cardiovascular disease, and difficulty in the management of diabetes. Frequent unintended hospitalizations and possible death can result.10–14 The importance of this study to clinical practice is that dental clinicians and policymakers need to use whatever methods possible to maintain routine long-term dental attendance patterns of our patients as they approach retirement age and before entering aged care facilities. The authors mentioned that the declining trend in routine dental attendance in Sweden coincided with a cutback in the dental insurance scheme, suggesting that the importance of good oral health, particularly in older adults, is not understood by some policymakers. Like all cohort studies, this study has some limitations. The authors mentioned the possibility of a healthy user effect, but noted that after adjusting for sociobehavioral factors the links between long-term dental attendance and clinical oral health and oral health-n-related quality of life were maintained. The authors also noted the possibility of inaccuracy with the exposure measurement because it was self-reported and some participants changed their attendance patterns over the course of the longitudinal study. The outcome measures were also self-reported. In the case of oral health-n-related quality of life, self-reporting is the only feasible mechanism for measurement. To measure major tooth loss, a clinical epidemiological examination would have been ideal, but difficult to do under the circumstances. It would have been appropriate for the authors to discuss what future research was needed in this area. It would be good to look at methods for improving longterm dental attendance patterns. Because the study com-
40
bined the reason for the dental visit (check-up/problem) with the time since last dental visit as the independent variable, it would be valuable for dental clinicians and policymakers to know which of the two, the reason or frequency of dental visiting, is the most important for improved clinical oral health and oral health-n-related quality of life outcomes.
REFERENCES 1. Chalmers J. Geriatric oral health issues in Australia. Int Dent J 2001;51:188-99. 2. Ettinger RL. Oral health and the ageing population. J Am Dent Assoc 2007;138:55-65. 3. Shay K. Infectious complications of dental and periodontal diseases in the elderly population. Clin Infect Dis 2002;34:1215-23. 4. Kandelman D, Petersen PE, Ueda H. Oral health, general health, and quality of life in older people. Spec Care Dent 2008;28:224-36. 5. Naito M, Yuasa H, Nomura Y, Nakayama T, Hamajima N, Hanada N. Oral health status and health-related quality of life: a systematic review. J Oral Sci 2006;48(1):1-7. 6. Goldberg LR, Heiss CJ. Assessing energy expenditure during eating in vulnerable older adults. Gerontologist 2012;52(S1):326. 7. Goldberg LR. Objective and perceptual measures of quality of life in older adults with dysphagia. Dysphagia 2012;27(4):581. 8. Goldberg LR, Heiss CJ, Foley AS, et al. Hydration in older adults: the contribution of bioelectrical impedance analysis. Int J Speech Lang Pathol 2014;16(3):273-81. 9. Terpenning M. Geriatric oral health and pneumonia risk. Aging Infect Dis 2005;40:1807-10. 10. Loesche WJ, Lopatin DE. Interactions between periodontal disease, medical diseases, and immunity in the older individual. Periodontology 2000;16(1):80-105. 11. Rautemaa R, Lauhio A, Cullinan MP, Seymour GJ. Oral infections and systemic disease – an emerging problem in medicine. Clin Microbiol Infect 2007;13:1041-7. 12. Seymour GJ, Ford PJ, Cullinan MP, Leishman S, Yamazaki K. Relationship between periodontal infections and systemic disease. Clin Microbiol Infect 2007;14(suppl 4):3-10. 13. Slade GD. Oral Health for Older People: Evaluation of the South Australian Dental Service Project. Cat. No. POH 6. Canberra: Australian Institute of Health and Welfare; 2007 (Population Oral Health Series No. 6). 14. Tsakos G, Steele JG, Marcenes W, Walls AW, Sheiham A. Clinical correlates of oral health-related quality of life: evidence from a national sample of British older people. Eur J Oral Sci 2006;114:391-5.
REVIEWER Leonard A. Crocombe Senior Research Fellow, Australian Research Centre of Population Oral Health, University of Adelaide, Australia [email protected] Associate Professor, Oral Health, Centre for Rural Health, University of Tasmania. Private Bag 103, Hobart, Tasmania 7001, Australia
March 2015
ARTICLE ANALYSIS & EVALUATION ARTICLE TITLE AND BIBLIOGRAPHIC INFORMATION Long-term routine dental attendance: influence on tooth loss and oral health-related quality of life in Swedish older adults. Astrøm AN, Ekback G, Ordell S, Nasir E. Community Dent Oral Epidemiol 2014;42(5):460-69.
Long-term Routine Dental Attendance is Important for Older Adults SUMMARY Subjects Subjects were persons born in 1942 residing in two counties in Sweden. The sample size was 4143 at follow-up (response rate 65%) after 5, 10, and 15 years. The birth cohort was age 50 to 65 years at the time of the four longitudinal surveys (1992, 1997, 2000, and 2007) and close to evenly split between genders (50.2% female).
REVIEWER Leonard A. Crocombe, BDSc, MBA, MPA, PhD
PURPOSE/QUESTION To investigate the effect of longterm dental attendance on oral health-n-related quality of life and tooth loss.
Key Exposure/Study Factor Long-term dental attendance was measured by asking the participants at each step of the longitudinal survey when their last dental visit was and who (dentist or self) or what was the initiative (check-up or problem) for the last dental visit. Routine dental attendance was defined as attendance within the preceding 12 months or in response to personal decision for regular check-ups. Non-routine dental attendance was defined as attendance less frequently than within the previous 12 months or in response to dental problems or pain. Long-term routine dental attendance was defined as routine dental attendance in both 1992 and 2007.
SOURCE OF FUNDING
Main Outcome Measure
Government: Department of Dentistry, Orebro County; The Dental Commissioning Unit, Ostergotland County, Sweden; NRC Grant 204887/V50.
Major tooth loss defined as participant-reported dentition status of missing many teeth or being edentulous. Oral health-n-related quality of life was measured by the eight-item impact of daily performance inventory (OIDP) obtained at the final (2007) survey only. This measure asked about difficulties with eating and enjoying food, speaking and pronouncing clearly, tooth cleaning, sleep and relaxation, smiling and showing teeth without being embarrassed, being emotionally stable, being sociable, and performing daily activities.
TYPE OF STUDY/DESIGN Cohort study
LEVEL OF EVIDENCE Level 2: Limited-quality, patientoriented evidence
STRENGTH OF RECOMMENDATION GRADE Not applicable
Main Results Adjusted logistic regression revealed that individuals reporting long-term routine dental attendance were 0.3 (95% confidence interval [CI]: 0.2–0.5) times less likely than non-routine attenders to report oral impacts. Generalized estimating equations indicated long-term routine dental attenders were 0.6 (95% CI: 0.4–0.7) times less likely than non-routine attenders to report major tooth loss.
Conclusions Compared with long-term non-regular dental attendance, long-term routine dental attendance was associated with lower major tooth loss and better oral health-n-related quality of life.
COMMENTARY AND ANALYSIS J Evid Base Dent Pract 2015;15:39-40 1532-3382/$36.00 Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jebdp.2015.01.003
This study shows the importance of long-term dental attendance for clinical oral health and oral health-n-related quality of life in individuals age 50 to 65 years. The study’s strengths are its large sample size, the statistical
JOURNAL OF EVIDENCE-BASED DENTAL PRACTICE
analysis that incorporated social demographic variables and sociobehavioral factors, and the fact that it is a longitudinal study. This last fact suggests that because the longterm dental attendance preceded the clinical oral health and oral health-n-related quality of life outcomes, the association between the independent and dependent variables may be causal. The study also showed that routine dental attendance decreased as people approached retirement age. This is of particular importance in a rapidly aging population and when we know that eating textured and nutritious foods becomes challenging in older adults and adults are at risk for inadequate nutrition, dehydration, and declining health.1–8 If older adults have poor oral hygiene and aspirate food or liquid into the lungs after swallowing, they are at risk for developing aspiration pneumonia.9 Other medical complications related to poor oral health include gastrointestinal dysfunction, cognitive decline, cardiovascular disease, and difficulty in the management of diabetes. Frequent unintended hospitalizations and possible death can result.10–14 The importance of this study to clinical practice is that dental clinicians and policymakers need to use whatever methods possible to maintain routine long-term dental attendance patterns of our patients as they approach retirement age and before entering aged care facilities. The authors mentioned that the declining trend in routine dental attendance in Sweden coincided with a cutback in the dental insurance scheme, suggesting that the importance of good oral health, particularly in older adults, is not understood by some policymakers. Like all cohort studies, this study has some limitations. The authors mentioned the possibility of a healthy user effect, but noted that after adjusting for sociobehavioral factors the links between long-term dental attendance and clinical oral health and oral health-n-related quality of life were maintained. The authors also noted the possibility of inaccuracy with the exposure measurement because it was self-reported and some participants changed their attendance patterns over the course of the longitudinal study. The outcome measures were also self-reported. In the case of oral health-n-related quality of life, self-reporting is the only feasible mechanism for measurement. To measure major tooth loss, a clinical epidemiological examination would have been ideal, but difficult to do under the circumstances. It would have been appropriate for the authors to discuss what future research was needed in this area. It would be good to look at methods for improving longterm dental attendance patterns. Because the study com-
40
bined the reason for the dental visit (check-up/problem) with the time since last dental visit as the independent variable, it would be valuable for dental clinicians and policymakers to know which of the two, the reason or frequency of dental visiting, is the most important for improved clinical oral health and oral health-n-related quality of life outcomes.
REFERENCES 1. Chalmers J. Geriatric oral health issues in Australia. Int Dent J 2001;51:188-99. 2. Ettinger RL. Oral health and the ageing population. J Am Dent Assoc 2007;138:55-65. 3. Shay K. Infectious complications of dental and periodontal diseases in the elderly population. Clin Infect Dis 2002;34:1215-23. 4. Kandelman D, Petersen PE, Ueda H. Oral health, general health, and quality of life in older people. Spec Care Dent 2008;28:224-36. 5. Naito M, Yuasa H, Nomura Y, Nakayama T, Hamajima N, Hanada N. Oral health status and health-related quality of life: a systematic review. J Oral Sci 2006;48(1):1-7. 6. Goldberg LR, Heiss CJ. Assessing energy expenditure during eating in vulnerable older adults. Gerontologist 2012;52(S1):326. 7. Goldberg LR. Objective and perceptual measures of quality of life in older adults with dysphagia. Dysphagia 2012;27(4):581. 8. Goldberg LR, Heiss CJ, Foley AS, et al. Hydration in older adults: the contribution of bioelectrical impedance analysis. Int J Speech Lang Pathol 2014;16(3):273-81. 9. Terpenning M. Geriatric oral health and pneumonia risk. Aging Infect Dis 2005;40:1807-10. 10. Loesche WJ, Lopatin DE. Interactions between periodontal disease, medical diseases, and immunity in the older individual. Periodontology 2000;16(1):80-105. 11. Rautemaa R, Lauhio A, Cullinan MP, Seymour GJ. Oral infections and systemic disease – an emerging problem in medicine. Clin Microbiol Infect 2007;13:1041-7. 12. Seymour GJ, Ford PJ, Cullinan MP, Leishman S, Yamazaki K. Relationship between periodontal infections and systemic disease. Clin Microbiol Infect 2007;14(suppl 4):3-10. 13. Slade GD. Oral Health for Older People: Evaluation of the South Australian Dental Service Project. Cat. No. POH 6. Canberra: Australian Institute of Health and Welfare; 2007 (Population Oral Health Series No. 6). 14. Tsakos G, Steele JG, Marcenes W, Walls AW, Sheiham A. Clinical correlates of oral health-related quality of life: evidence from a national sample of British older people. Eur J Oral Sci 2006;114:391-5.
REVIEWER Leonard A. Crocombe Senior Research Fellow, Australian Research Centre of Population Oral Health, University of Adelaide, Australia [email protected] Associate Professor, Oral Health, Centre for Rural Health, University of Tasmania. Private Bag 103, Hobart, Tasmania 7001, Australia
March 2015
