Ronald L. Ettinger

Public Health Issues in Geriatric Dentistry in the United States

The aging United States population living in the new millennium has dental needs that are very different and more complex than those experienced by previous older adult cohorts during the twentieth century. The type of dental care to be provided for older Americans goes way beyond emergency care, extractions and denture care. Dental caries is still clearly a public health problem for subgroups of older Americans, such as those of lower socioeconomic status, with dementia, who are homebound and who are institutionalized. These are also the subgroups experiencing greater barriers to accessing dental care. Stakeholders, including dental professionals and the dental benefits industry, need to work together to develop innovative dental financing programs that will increase older Americans access to dental care.

A 30‐year review of a geriatric dentistry teaching programme

OBJECTIVE To review the development of the Geriatric Dental and Special Needs Education programme at the University of Iowa over the last 30 years. BACKGROUND The programme at Iowa evolved from a didactic elective programme taught by a single faculty person to a required didactic and clinical programme, which includes a Special Care Clinic in the dental school and a mobile unit with portable dental equipment which serves ten area nursing homes with comprehensive care. MATERIALS AND METHODS Changes have been made in the programme over time based on formal and informal feedback from students and graduates, and we have also looked at the impact of the programme on dental services to our target population. RESULTS The factors influencing the curriculum development are identified and discussed. CONCLUSION As no dental schools are the same, some general applications are suggested from the Iowa experience.

Treatment planning concepts for the ageing patient

There is an ageing imperative in Australia as in many other industrialized nations, and these populations are extremely heterogeneous. In young adults, the factors which influence decision making for oral health care are whether the patient has the will, the time or the finances to pay for care, while for clinicians, the decisions are whether they have the skill and the resources to carry out the treatment plan. For older adults, the decision making includes all of the previous identified factors, but they are now complicated by the patients medical and medication problems, the side effects of the medications they are taking, their cognitive status as well as the cumulative effects of a lifetime of physiological, traumatic and iatrogenic effects on the dentition and the oral cavity. The decision-making process which has evolved has been called many names, from cost-effective care to minimal invasive dentistry to rational dental care. Fundamentally, they are similar. Rational dental care has been defined as the process of decision making, which develops a treatment plan that is in the best interest of the patient after evaluating all of the modifying factors. This article will discuss the various concepts, and the strengths and weaknesses of some of these systems. It will also illustrate some of the clinical problems as there is very little evidence-based data to support any of these concepts. However, treatment planning is still an art, which can only be carried out for an individual and not a group, and the result must serve the needs of the patient and enhance the quality of his or her life.

Opinions on the provision of dental care in Iowa nursing homes

Using a stratified random sample, a questionnaire was mailed to 400 practicing dentists and 200 directors of nursing (DONs). Response rates were 58.3% for dentists and 50% for DONs. Dentists were representative of Iowa dentists, with 85% male, mean age 49.1 years, and 22.4 years in practice. All DONs were female, with mean age of 44.9 years. Of the participating dentists, 86% had provided dental care for nursing home residents, but the majority of care was completed in dental offices. Three-quarters of dentists were somewhat/not interested in nursing home dentistry. Dentists and DONs held common perceptions of the most frequent problems related to care provision at nursing homes: low financial reimbursement, especially for Medicaid patients; no portable dental equipment; no suitable area for dentistry; dentists preference to treat patients at their dental practice; and transportation of residents to a dental practice. Dentists and DONs had some differing perceptions about oral health care (p < .01). Minimal dental care was provided on-site at Iowa nursing homes.

Geriatric dentistry in the USA: looking back 30 years.

When I finished my prosthodontic training nearly 50 years ago, the issues in geriatric dentistry were relatively clear. Most older people were edentate and sought dental care only when their mouth and denture problems could be ignored no longer. The most challenging problem for this ageing population facing dentists was the complete denture on a severely resorbed ridge. There was no concept of need for special education to care for the ageing population. However, if you as on older person had a problem with your complete denture, you or your family could remove it, and you could eat softened food or food from a blender. This change in diet was not considered a problem. However, current research suggests that it does affect nutrition as well as quality of life, morbidity and mortality. Today we see some evidence that edentulous people have an increased risk of a stroke when compared to people with natural teeth. The majority of older people today in the industrialised world has natural teeth, which has changed the challenge for dentists. An older person with a toothache is likely to seek out a dentist, and the dentist will likely need to use a local anaesthetic, analgesics and possibly antibiotics. Local anaesthetics usually contain epinephrine, which reacts with many drugs and can have cardiovascular side effects. Further, dentists need a solid grounding in pharmacology and medicine. Jim Beck and I highlighted the special needs of several subgroups of the older population. In the USA, for example, people who are functionally independent make up about 70% of the population over 65 years of age, and they can access dental offices and be cared for by most general dentists. However, older people who are frail constitute about 20% of over 65s, and, although many of them can get to a dentist with help from a third party, some need special care from a dentist with extra training in geriatric dentistry. But the greatest challenge comes with people who are functionally dependent (5% are homebound and 5% live in long-term care facilities) because of disabling physical and/or mental impairments. They really do need special care. Indeed, with increasing life expectancy in most countries, this very dependent group will increase dramatically in the near future. Therefore, the discipline of geriatric dentistry needs to emerge from the shadow of general dentistry as a dental specialty. Geriatric education in the USA

Incidence of attachment loss of canines in an overdenture population

STATEMENT OF PROBLEM Caries and periodontal disease are the most common cause of tooth loss in overdenture populations. Longitudinal data on attachment loss in this population have not been well reported. PURPOSE The purpose of this longitudinal study was to measure periodontal attachment loss in overdenture abutments. MATERIAL AND METHODS In this longitudinal overdenture study, 272 persons fulfilled all of the inclusion criteria. These persons had 662 teeth, 465 (70.2%) of which were canines. This report focused only on participants with canines who returned for 3 consecutive recalls in the 42 months of the study and included 53 persons with 116 canines. During this 42-month period, 6 teeth were extracted. Attachment loss was measured at baseline and at 6 to 18 months, 19 to 30 months, and 31 to 42 months at the mesial, distal, mid-buccal, and mid-lingual surface of each tooth, and was calculated as the combination of pocket probing depth plus height above the gingiva. Attachment loss was compared at each recall. A single examiner made all the measurements. RESULTS At baseline, the greatest amount of loss was at the mid-buccal surface (5.43 mm), followed by the mid-lingual (4.95 mm), distal (4.41 mm), and mesial (4.35 mm) surfaces. This pattern of attachment loss did not change over the 3 time periods, except that, at the 6 to 18-month recall, the distal measurement was less than at baseline. This decrease could be due to the wear of the abutment or loss of a restoration due to caries. Attachment loss was greater on the mandibular abutments than on the maxillary abutments and could be due to the greater amount of movement of the mandibular overdenture, especially in a buccolingual direction. CONCLUSION Attachment loss varied by arch and by site in patients who wore overdentures.

The involvement of Iowa dentists in hospice care

The relationships between dentist characteristics and professional education with involvement of Iowa dentists in hospice care were investigated. Using the 1999 Iowa Health Professional database, a survey requesting information regarding involvement in and training for care of hospice patients was mailed to all licensed dentists (N = 1,210). Two mailings yielded a 54.6% response rate. Of the 638 dentist respondents, the mean age was 47, 86% were male, 88% general dentists, and 295 (46%) reported providing some treatment for hospice patients. At least one dentist reported providing hospice patient care in 72 of Iowas 99 counties. About 90% of dentists treating hospice patients were general practitioners. Males were more likely to provide treatment (p < 0.0313). Neither dentist age nor years in practice were significant predictors. Dentists were more likely to treat hospice patients in the office (IO, 40%). The most prevalent treatments were denture relines (31% IO; 71% OO), examinations (16% IO; 68% OO), and emergency treatment (12.5% IO; 53% OO). More than 86% of surveyed dentists indicated that their professional education did not adequately train them to meet the clinical, psychosocial, communication, or spiritual needs of hospice patients.

Management of a failed mandibular staple implant: A clinical report

A 48-year-old woman sought treatment because her staple implant-retained overdenture was no longer retentive, and the denture was worn over the abutments. After unsuccessfully attempting to move the retentive nuts along the transosseous posts of the staple implant, the posts were cut off at the level of the bone. Two endosseous implants were placed around the staple implant, and a new implant-retained overdenture was fabricated and inserted using ball attachments for retention. This article describes the treatment for this patient, who has been wearing the new dentures successfully for the past 4 years.