Martina Hayes

Risk indicators associated with root caries in independently living older adults

OBJECTIVE To determine the risk indicators associated with root caries experience in a cohort of independently living older adults in Ireland. METHODS The data reported in the present study were obtained from a prospective longitudinal study conducted in a cohort of independently living older adults (n=334). Each subject underwent an oral examination, performed by a single calibrated examiner, to determine the root caries index and other clinical variables. Questionnaires were used to collect data on oral hygiene habits, diet, smoking and alcohol habits and education level. A regression analysis with the outcome variable of root caries experience (no/yes) was conducted. RESULTS A total of 334 older dentate adults with a mean age of 69.1 years were examined. 53.3% had at least one filled or decayed root surface. The median root caries index was 3.13 (IQR 0.00, 13.92). The results from the multivariate regression analysis indicated that individuals with poor plaque control (OR 9.59, 95% CI 3.84-24.00), xerostomia (OR 18.49, 95% CI 2.00-172.80), two or more teeth with coronal decay (OR 4.50, 95% CI 2.02-10.02) and 37 or more exposed root surfaces (OR 5.48, 95% CI 2.49-12.01) were more likely to have been affected by root caries. CONCLUSIONS The prevalence of root caries was high in this cohort. This study suggests a correlation between root caries and the variables poor plaque control, xerostomia, coronal decay (≥2 teeth affected) and exposed root surfaces (≥37). The significance of these risk indicators and the resulting prediction model should be further evaluated in a prospective study of root caries incidence. CLINICAL SIGNIFICANCE Identification of risk indicators for root caries in independently living older adults would facilitate dental practitioners to identify those who would benefit most from interventions aimed at prevention.

Strategies to prevent oral disease in dependent older people

To assess the effects and costs of primary, secondary and tertiary strategies to prevent oral disease in dependent older people.

Failure rates of class V restorations in the management of root caries in adults – a systematic review

OBJECTIVE The aim of this systematic review was to compare cumulative failure rates of different restorative materials in carious class V lesions on the root surfaces of adult patients. BACKGROUND The prevalence of root caries is set to increase in the coming years as a result of ageing of the population and a concomitant reduction in levels of edentulousness. Evidence is needed to assist practitioners to select the most appropriate restorative material for use in these lesions. METHODS A search of the literature was undertaken using the electronic databases of PubMed, Embase, CENTRAL and OpenSIGLE using keywords relevant to the search question. Two review authors conducted the electronic search independently, and any conflict was resolved by discussion. The references quoted in the full text articles extracted were hand searched for any further eligible studies. RESULTS Sixty non-duplicate citations were screened. Following review of the titles, abstracts, texts and application of the pre-determined inclusion/exclusion criteria, five studies remained. CONCLUSION There is a need for more research in this area as many of the studies identified in this systematic review treated post-radiation, xerostomic patients which are not typical of the general population. Increased adherence to CONSORT guidelines for reporting is also advised to facilitate future systematic review and meta-analysis in this area.

Topical agents for root caries prevention

Data sourcesPubMed, EMBASE and Cochrane Central Register of Controlled Trials.Study selectionRandomised and nonrandomised, controlled, and prospective studies comparing preventive regimes for root caries were considered. Only English or German language studies were considered.Data extraction and synthesisStandard data items were extracted. Mean differences (MD) and standard mean differences (SMD) were primary effect measures. Changes were calculated for DMFRS/DFRS (decayed, missing, filled root surfaces), and RCI (root caries index). Random-effects meta-analysis was conducted. Study quality was assessed using the Cochrane risk of bias tool and grading of evidence was performed according to the GRADE.ResultsThirty trials reported in 34 studies involving 10,126 patients were included. Twenty-nine were RCTs, the other a controlled trial. Risk of bias was considered low for only five studies. In all 28 chemical agents were tested. Eleven studies assessed dentifrices; ten rinses; eight varnishes; three fluoride solutions; three gels; two ozone applications; one preventive dental regimen. Meta-analyses revealed that dentifrices containing 5,000 ppm F- (RR = 0.49; 95% CI= 0.42, 0.57; high level of evidence) or 1.5% arginine plus 1,450 ppm F- (RR = 0.79; 95% CI = 0.64, 0.98; very low level) are more effective in inactivating RCLs than dentifrices containing 1,100 to 1,450 ppm F-. Self-applied AmF/SnF2-containing dentifrice and rinse decreased the initiation of RCLs when compared with NaF products (SMD = 0.15; 95% CI = −0.22, 0.52; low level evidence). Mouth rinse containing 225 to 900 ppm F- revealed a significantly reduced DMFRS/DFRS (MD = −0.18; 95% CI = −0.35, −0.01; low level) when compared with a placebo rinse. Significantly reduced RCI was found for Chlorhexidine (MD = −0.67; 95% CI = −1.01, −0.32; very low level evidence) as well as SDF (MD = −0.33; 95% CI = −0.39, −0.28; very low level) when compared with placebo varnish.ConclusionsBased on meta-analysis, dentifrice containing 5,000 ppm F- and professionally applied CHX or SDF varnish may inactivate existing and/or reduce the initiation of RCLs. However, results should be interpreted with caution due to the low numbers of clinical trials for each agent, the high risk of bias within studies, and the limiting grade of evidence.

Evaluation of Biodentine in the Restoration of Root Caries A Randomized Controlled Trial

There is no “gold-standard” material for the operative management of root caries. The aim of this study was to determine if the clinical performance of Biodentine would be acceptable for the restoration of root caries in older adults. A randomized controlled clinical trial was conducted comparing a calcium silicate cement (Biodentine), a high-viscosity glass ionomer cement (Fuji IX GP Extra), and a resin-modified glass ionomer cement (Fuji II LC). Of the 334 volunteers assessed for eligibility, 249 were excluded. A total of 303 lesions in 85 participants were randomized, with 151 lesions allocated to receive Biodentine, 77 to Fuji IX GP Extra, and 77 to Fuji II LC. Patients were reviewed by a calibrated dentist who was not involved in restoration placement and who was blinded to material allocation. Restorations were assessed according to a modified US Public Health Service criteria. The cumulative survival percentages after 6 mo and 1 y were 58.6% and 47.2% in the Biodentine group, 89.6% and 83.8% in the Fuji IX GP Extra group, and 89.5% and 84.9% in the Fuji II LC group, respectively. There were statistically significant differences (χ2 test, P < 0.001) in restoration failure rates between restoration groups. There was no difference between Fuji IX GP Extra and Fuji II LC, but differences (P < 0.001) were shown between the Fuji II GP Extra group and the Biodentine group and also between the Fuji II LC group and the Biodentine group at both time points. Based on the results of this study, Biodentine cannot be recommended for the operative management of root caries. Fuji IX GP Extra and Fuji II LC displayed similar success rates, and high-viscosity glass ionomer cement and resin-modified glass ionomer cement continue to be the best available option for the restoration of root caries (ClinicalTrials.gov NCT01866059). Knowledge Transfer Statement: The results of this study can assist dental practitioners when selecting a restorative material for the operative management of root caries. This randomized controlled trial compared the 1-y clinical performance of a calcium silicate–based material to that of a high-viscosity glass ionomer cement and a resin-modified glass ionomer cement in the operative management of root caries. The study concluded that high-viscosity glass ionomer cement and resin-modified glass ionomer cement continue to be the best available option to dental practitioners when restoring the root surface.

Impact of oral rehabilitation on the quality of life of partially dentate elders in a randomised controlled clinical trial: 2 year follow-up

Objective This randomised clinical trial aimed to compare the impact of two different tooth replacement strategies for partially dentate older patients namely; removable partial dentures (RPDs) and functionally orientated treatment based on the shortened dental arch (SDA) concept, on Oral Health-related Quality of Life (OHrQOL). Methods 89 patients completed a randomised clinical trial. Patients were recruited in two centres: Cork University Dental Hospital (CUDH) and a Geriatric Day Hospital (SFDH). 44 patients were randomly allocated to the RPD group and 45 to the SDA group where adhesive bridgework was used to provide 10 pairs of occluding contacts. The impact of treatment on OHrQOL was used as the primary outcome measure. Each patient completed the Oral Health Impact Profile (OHIP-14) at baseline, 1, 6, 12 and 24 months after treatment. Results Both treatment groups reported improvements in OHIP-14 scores at 24 months (p<0.05). For the SDA group OHIP-14 scores improved by 8.0 scale points at 12 months (p<0.001) and 5.9 scale points at 24 months (p<0.05). For the RPD group OHIP-14 scores improved by 5.7 scale points at 12 months (p<0.05) and 4.2 scale points at 24 months (p<0.05). Analysis using ANCOVA showed that there were significant between group differences recorded in both treatment centres. 24 months after intervention the SDA group recorded better OHIP-14 scores by an average of 2.9 points in CUDH (p<0.0001) and by an average of 7.9 points in SFDH (p<0.0001) compared to the RPD group. Conclusions Patients in the SDA group maintained their improvements in OHrQOL scores throughout the 24 month study period. For the RPD group the initial improvement in OHrQOL score began to diminish after 6 months, particularly for those treated in SFDH. Thus, the benefits of functionally orientated treatment increased over time, particularly for the older, more systemically unwell cohort in SFDH.

17 Evidence based practice education for healthcare professions – an international multidisciplinary perspective

Objectives To ascertain current practice and provision of EBP education across healthcare professions at undergraduate, postgraduate and continuing professional development programme levels for the purpose of making key recommendations to healthcare educators and policy makers in relation to ‘best practice’ for EBP education. Method Three distinct but interlinked phases of research were conducted. In phase 1, a desktop rapid review was undertaken to provide a contextualised succinct synthesis of literature relating to the competencies and programme components associated with EBP education. In phase 2, interviews with experts (n=5) in evidence based practice education were conducted to ascertain current and nuanced information on EBP education from an international perspective (Australia, New Zealand, Canada, United Kingdom). In Phase 3,a descriptive, cross-sectional, national, online survey was undertaken to capture and describe baseline data relating to the current provision and practice of EBP education to healthcare professionals at third level institutions and professional training/regulatory bodies in Ireland. Results A narrative synthesis of 83 empirical studies revealed that participation in any form of EBP education has beneficial effects across all EBP competencies with the most apparent positive trend derived from multi-modal teaching and learning interventions. Analysis of EBp expert interview data provided definitive advice in relation to: (i) EBP curriculum considerations; (ii) Teaching EBP and (iii) Stakeholder engagement in EBP education. Representation from 11 healthcare professions across academic levels was obtained from the national survey conducted in Phase 3. A considerable amount of EBP activity throughout health profession education was apparent, with strong recognition of the need for EBP principles and processes within curricula to achieve core professional competencies. However, effectively embedding EBP throughout health education curricula requires further strategic development. Conclusions Despite positive attitudes towards EBP and a predominant recognition of its necessity for the delivery of quality and safe healthcare, its consistent translation at the point of care remains elusive. An examination of current discourse between academic and clinical educators across healthcare professions is required to progress a ‘real world’ pragmatic approach to the integration of EBP education which has meaningful relevance to students and engenders active engagement from educators, clinicians and policy-makers alike.

How do we incorporate patient views into the design of healthcare services for older people: a discussion paper

BackgroundAcross the European Union costs for the treatment of oral disease is expected to rise to €93 Billion by 2020 and be higher than those for stroke and dementia combined. A significant proportion of these costs will relate to the provision of care for older people. Dental caries severity and experience is now a major public health issue in older people and periodontal disease disproportionately affects older adults. Poor oral health impacts on older people’s quality of life, their self-esteem, general health and diet. Oral health care service provision for older people is often unavailable or poor, as is the standard of knowledge amongst formal and informal carers. The aim of this discussion paper is to explore some of the approaches that could be taken to improve the level of co-production in the design of healthcare services for older people.Main textPeople’s emotional and practical response to challenges in health and well-being and the responsiveness of systems to their needs is crucial to improve the quality of service provision. This is a particularly important aspect of care for older people as felt, expressed and normative needs may be fundamentally different and vary as they become increasingly dependent. Co-production shifts the design process away from the traditional ‘top-down’ medical model, where needs assessments are undertaken by someone external to a community and strategies are devised that encourage these communities to become passive recipients of services. Instead, an inductive paradigm of partnership working and shared leadership is actively encouraged to set priorities and ultimately helps improve the translational gap between research, health policy and health-service provision.DiscussionThe four methodological approaches discussed in this paper (Priority Setting Partnerships, Discrete Choice Experiments, Core Outcome Sets and Experience Based Co-Design) represent an approach that seeks to better engage with older people and ensure an inductive, co-produced process to the research and design of healthcare services of the future. These methods facilitate partnerships between researchers, healthcare professionals and patients to produce more responsive and appropriate public services for older people.

Etiology, Risk Factors and Groups of Risk

Population aging and the concomitant reduction in tooth loss will have a profound effect on dentistry. In particular, an increase in the prevalence of root caries can be expected. Root caries is not evenly distributed across the population and identification of high-risk groups or individuals would facilitate targeted prevention strategies. Unfortunately, the lack of consensus in the literature on the diagnosis and measurement of root caries makes comparison of studies extremely challenging. At present, we do not have an adequately validated risk assessment tool for root caries. Future research should focus resources on investigating risk indicators, which have been found to be significant in past studies and on externally validating previously described risk models.

Incidence, Prevalence and Global Distribution of Root Caries

High quality epidemiological data are essential for both the development of national oral health policies and cost-effective targeting of resources. Unfortunately, a high level of clinical heterogeneity between studies in this area makes it difficult, and inappropriate, to try to produce any definitive figures on the global prevalence or incidence of root caries. Published studies have reported wide ranges for the prevalence of root caries (25-100%) and the mean Root Caries Index (9.7-38.7). The reported range for annual root caries incidence is also wide, from 10.1 to 40.6%. While more research is needed in this area, most studies conclude that the burden of root caries is high in the older age population.