Pattern of Tooth Loss in Older Adults with Dementia Under

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

Care

Xi Chen, DDS, PhDAssistant Professor

Department of Dental Ecology

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Introduction

• 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

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Oral Health Issues in 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

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Oral Health Issues in 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 .

Oral Health Issues in Older Adults with Dementia

• Increased prevalence of edentulism

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Oral Health Issues in Older Adults with Dementia

• Decreased use of dentures over time

• Increased denture- related soft tissue problems

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Oral Health Issues in Older Adults with Dementia

• Increased prevalence of soft tissue lesions

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Introduction

• 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

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Introduction

• 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

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Methods

• 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

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Methods

• 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)

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Methods

• Determination of enrollment period

Methods• 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

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Methods

• 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

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Methods

• Addressing potential confounders– Age– Residential status– Anticholinergic effect of medication– Physical mobility etc.

Tooth Loss

AgeDementia

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Methods• Addressing potential confounders

– Propensity Score Matching

ppdementednonP

dementedPIn

332211)(

)(

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Methods

• 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

Results

Demographic characteristics of study subjects

Non-demented Group (N=372)

Demented Group (N=119)

P value

Length of enrollment 39.2 37.5 0.4598

Age at enrollment 73.8 81.5 <.0001

Gender Male 29.6 25.20.3592

Female 70.4 74.8

Dental insurance

No 33.1 15.10.0002

Yes 66.9 84.9

Residential status

Community 65.6 10.1

<.0001 Assisted living 9.4 4.2

Nursing home 25.0 85.7

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ResultsDental assessment at first arrival

Non-demented Group (N=372)

Demented Group (N=119)

P value

Number of remaining teeth 19.6 18.1 0.0610

Number of decayed/broken teeth 3.1 4.2 0.0056

Number of teeth with restoration 11.4 10.4 0.1439

Percent of decayed/broken teeth among the remaining teeth 18.5 27.4 0.0006

Percent of filled teeth among the remaining teeth 57.5 56.2 0.6070

Calculus / Plaque / Gingival bleeding (%)

None 1.2 0.9

<.0001Small to moderate 85.5 67.9

High 13.3 31.3

Use of prosthesis at arrival (%)

No 65.6 67.20.7431

Yes 34.4 32.804/13/23 19Xi Chen, UNC School of Dentistry

ResultsMedical assessment

Non-demented Group (N=372)

Demented Group (N=119)

P value

Number of medical conditions 5.9 9.5 <.0001

Burden of comorbidity (Charlson comorbidity index) 1.0 1.8 <.0001

Number of medications 6.2 7.9 0.0003

Sum of ADS* of current medications 1.8 2.3 0.0433

Maximum of ADS * of current medications (%)

0 39.7 18.1

0.0002 1 37.0 56.0

2 7.6 9.5

3 15.8 16.4

* ADS – Anticholinergic Drug Scale 04/13/23 20Xi Chen, UNC School of Dentistry

ResultsCognitive and functional assessment

Non-demented Group (N=372)

Demented Group (N=119)

P value

Cognitive impairment (%)

None 82.9 2.5

<0.0001Questionable 4.1 0.9

Slight 8.7 43.2

Moderate to severe 4.4 53.4

Physical mobility (%)

Walk independently 66.5 17.1

<0.0001

Need walker 19.2 30.8

Need help in transfer 14.3 51.3

Bedridden 0 0.9

Capacity to perform oral hygiene (%)

Self sufficient 84.0 21.0

<0.0001Need help 16.0 74.0

Won’t cooperate 0 5.004/13/23 21Xi Chen, UNC School of Dentistry

Results

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

Demented Group

Non-demented Group P value

Percent of subjects with tooth loss events 28.6 26.9 0.7187

Mean number of teeth lost among the subjects with tooth loss events 2.7 2.4 0.4737

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Results

TimePercent with tooth loss event

Non-demented Demented

12 m 11.3 10.8

24 m 21.1 23.8

36 m 26.4 33.2

48 m 31.0 37.3

60 m 38.4 37.3

Tooth survival

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

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Results

Rate of tooth loss events per patient year

Rate of tooth loss per 100 patient-year (SE)

95% confidence interval

P Value

Demented group14.9 (2.04) (11.4, 19.5)

0.9943 Non-demented group

14.9 (1.36) (12.4, 17.8)

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

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Results

Number of teeth lost per patient per 5 years

Number of teeth lost per patient per 5 years (SE)

95% confidence interval

P Value

Demented group1.21 (0.25) (0.80, 1.82)

0.4764 Non-demented group

1.01 (0.15) (0.76, 1.34)

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)

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Discussion

• 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

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Discussion

• 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

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Discussion• 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%)

Discussion

• 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

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Conclusion• 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

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Acknowledgement

• 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

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