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Pattern of Tooth loss in Older Adults with Dementia Under Current Model of
Care
Xi Chen, DDS, PhDAssistant Professor
Department of Dental Ecology
04/13/23 1Xi Chen, UNC School of Dentistry
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
04/13/23 Xi Chen, UNC School of Dentistry 2
04/13/23 Xi Chen, UNC School of Dentistry 3
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
04/13/23 Xi Chen, UNC School of Dentistry 4
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
04/13/23 7Xi Chen, UNC School of Dentistry
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
04/13/23 8Xi Chen, UNC School of Dentistry
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
04/13/23 9Xi Chen, UNC School of Dentistry
04/13/23 Xi Chen, UNC School of Dentistry 10
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)
04/13/23 Xi Chen, UNC School of Dentistry 12
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
04/13/23 13Xi Chen, UNC School of Dentistry
04/13/23 Xi Chen, UNC School of Dentistry 14
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)(
)(
04/13/23 Xi Chen, UNC School of Dentistry 17
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
04/13/23 18Xi Chen, UNC School of Dentistry
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
04/13/23 22Xi Chen, UNC School of Dentistry
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)
04/13/23 23Xi Chen, UNC School of Dentistry
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)
04/13/23 24Xi Chen, UNC School of Dentistry
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)
04/13/23 25Xi Chen, UNC School of Dentistry
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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
04/13/23 Xi Chen, UNC School of Dentistry 27
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
04/13/23 29Xi Chen, UNC School of Dentistry
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
04/13/23 30Xi Chen, UNC School of Dentistry
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
04/13/23 31Xi Chen, UNC School of Dentistry