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R E S E A R C H
F
D
ined the oral health of
elderly people with
ABSTRACT ✷
J
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®
dementia.1,2 The majority
N
CON
IO
of these are cross- determine one-year coronal and root caries increments
T
sectional surveys, with some
A
in patients newly diagnosed as having Alzheimer N
I
U C
IN U
addressing only overall dental and disease (AD), other dementia (OD) or no dementia. A G ED
4
RT
denture status,3,4 others reporting Methods. The authors recruited patients from two hos- ICLE
findings regarding carious teeth or pital memory clinics in Copenhagen. The oral examination included an
decayed, missing or filled teeth assessment of dental status and dental caries. The authors used a struc-
(DMFT)5-7 and a small number tured questionnaire to obtain information regarding demographic, social and
reporting results at the tooth- functional variables.
surface level.4,8-10 However, few Results. In the baseline study, 106 dentate patients participated. Of these,
longitudinal studies have investi- 77 completed the follow-up study. The participants’ mean age was 81.9 years
gated the relationship between de- at baseline and 82.5 years at follow-up. At baseline, 87 (82 percent) of 106
mentia and caries incidence and participants had dementia and at follow-up, 64 (83 percent) of 77 partici-
increments over time.11-14 pants had dementia. The mean number of decayed tooth surfaces was signif-
Jones and colleagues13 found icantly higher at follow-up than at baseline for all participants, and the
that male patients with Alz- number was highest for the OD group. The one-year adjusted caries and
heimer disease (AD) tended to filling increments (ADJCIs) were high for participants with and without
have higher mean increments dementia but were highest for participants in the AD and OD groups. Base-
(that is, the number of new sur- line risk factors for developing elevated coronal and root ADJCIs included
faces with caries at follow-up) of having caries, having many teeth and being older than 80 years.
coronal and root caries than did Conclusions. Elderly people referred to a memory clinic were at an ele-
control subjects without demen- vated risk of developing high levels of coronal and root-surface caries during
tia. In another longitudinal study, the first year after referral, and those with a dementia diagnosis other than
Ship and Puckett14 reported that AD appeared to be at a particularly high risk of developing multiple carious
patients with AD had notably lesions during the first year after diagnosis.
higher DMFT scores and a Clinical Implications. These findings underscore the importance of
greater number of filled coronal addressing the oral health needs of elderly people suspected of having expe-
and cervical surfaces than did rienced cognitive decline.
control subjects without demen- Key Words. Alzheimer disease; caries; dental care for elderly patients;
tia; however, the longitudinal nursing homes; oral health; research.
changes were not statistically dif- JADA 2009;140(11):1392-1400.
ferent between the two groups. In
Dr. Ellefsen is an assistant professor, Copenhagen Gerontological Oral Health Research Center, School of Dentistry, University of Copenhagen, Norre Allé 20,
Copenhagen DK-2200 CPH N, Denmark, e-mail “bel@odont.ku.dk”. Address reprint requests to Dr. Ellefsen.
Dr. Holm-Pedersen is a professor, Copenhagen Gerontological Oral Health Research Center, School of Dentistry, University of Copenhagen.
Dr. Morse is an associate professor, Department of Epidemiology and Health Promotion, New York University, College of Dentistry, New York City.
Dr. Schroll is a professor, Department of Geriatric Medicine, Bispebjerg University Hospital, Copenhagen.
Dr. Andersen is a consultant neurologist, Memory Disorders Research Group, Department of Neurology, Copenhagen University Hospital, Rigshospitalet.
Dr. Waldemar is a professor, Memory Disorders Research Group, Department of Neurology, Copenhagen University Hospital, Rigshospitalet.
these two studies, small sample sizes may have eases, 10th Revision.19
precluded the detection of statistically significant Both the baseline and one-year follow-up oral
differences in caries incidence and increments examinations were conducted by the same dentist
between participants with AD and control sub- (B.E.) in the participants’ homes with the use of a
jects without dementia. mobile dental unit that included a fiber optic
Chalmers and colleagues11 followed up a larger light, suction and an air-water syringe. The den-
group of community-dwelling older adults across tist performed the examinations according to
a one-year period and found that the incidence National Institute of Dental Research20 criteria
and increments of coronal and root caries were for coronal and root decayed surfaces (DSs) and
significantly higher among older adults with filled surfaces (FSs). The dentist recorded coronal
dementia than among those without dementia. caries and restorations for five surfaces on molars
The results of their study were in agreement with and premolars and for four surfaces on canines
those of other studies, which showed that caries and incisors. She recorded root caries and restora-
experience was related to dementia severity but tions for four surfaces on each tooth. We defined
not to a specific dementia diagnosis.9-11,13,15,16 gingival recession as being present if 1 millimeter
In a recent study of people referred to memory or more of the root surface was visible below the
During the follow-up clinical oral examination, of a partial denture (yes versus no) and number of
which was performed in the same manner as the medications (≤ three versus > three), as well as
baseline examination, the dentist collected infor- self-reported marital status, children (yes versus
mation about several clinical parameters no), MMSE scores (≥ 24 versus 0 to 23 [the lower
including dental status (that is, teeth present), the score, the greater the cognitive impairment]),
caries and periodontal status, and dental pros- housing (own versus rent versus nursing home or
thesis status. The same examiner (B.E.) con- equivalent), education (≤ seven years versus
ducted all caries assessments at baseline and > seven years), self-rated health (good versus fair-
follow-up. At all examinations, the examiner was poor), oral hygiene (toothbrushing daily versus
unaware of the dementia status of the study par- less than daily), self-rated disease (no disease
ticipants. The follow-up interview consisted of the versus any disease), dental visit habits (regularly
same questions as those administered at versus less than once a year) and xerostomia.
baseline.17 Additional covariates included mobility (MOB)
Primary outcome variables. The primary function22-24 and Instrumental Activities of Daily
outcome variables were as follows: Living (IADL).25 Items used in the MOB scale
dcrude caries and filling increments (CCIs), net include activities of daily living (ADL)26 related to
changing from filled to carious, which is consid- present or not, but we did not consider whether
ered an increment but does not change the surfaces or teeth were restorable.7
number of DFSs, and surfaces changing from
filled or decayed to missing or unexamined, which CONCLUSION
reduces the number of DFSs but does not affect The primary findings of this study are that
the number of increments. Other factors that elderly people referred to a memory clinic were at
could affect the difference in the number of DFSs an elevated risk of developing high levels of
and increments are reversals (that is, when a sur- coronal and root surface caries during the first
face changes from active caries to inactive caries) year after referral (independent of whether or not
or examiner reversals, which make both the DFS they fulfilled the criteria for a dementia diag-
difference and increments smaller (except for the nosis), and that elderly people with a dementia
CCI, for which the reversals are subtracted from diagnosis other than AD appeared to be at a par-
the increments). ticularly high risk of developing multiple carious
In our analysis, we identified baseline risk lesions during the first year after diagnosis. We
indicators for new root and coronal carious sur- identified a number of baseline characteristics
faces that developed during the follow-up year. that were associated with the development of
Caries experience in existing and new nursing home residents in Ade- 23. Avlund K, Kreiner S, Schultz-Larsen K. Construct validation and
laide, Australia. Gerodontology 2002;19(1):30-40. the Rasch model: functional ability of healthy elderly people. Scand J
13. Jones JA, Lavallee N, Alman J, Sinclair C, Garcia RI. Caries inci- Soc Med 1993;21(4):233-246.
dence in patients with dementia. Gerodontology 1993;10(2):76-82. 24. Avlund K, Kreiner S, Schultz-Larsen K. Functional ability scales
14. Ship JA, Puckett SA. Longitudinal study on oral health in sub- for the elderly: a validation study. Eur J Public Health 1996;6:35-42.
jects with Alzheimer’s disease. J Am Geriatr Soc 1994;42(1):57-63. 25. Barberger-Gateau P, Commenges D, Gagnon M, Letenneur L,
15. Chalmers JM, Carter KD, Spencer AJ. Oral diseases and condi- Sauvel C, Dartigues JF. Instrumental activities of daily living as a
tions in community-living older adults with and without dementia. screening tool for cognitive impairment and dementia in elderly com-
Spec Care Dentist 2003;23(1):7-17. munity dwellers. J Am Geriatr Soc 1992;40(11):1129-1134.
16. Chalmers JM, Carter KD, Spencer AJ. Caries incidence and 26. Katz S, Ford AB, Moskowitz RW, Jackson BA, Jaffe MW. Studies
increments in Adelaide nursing home residents. Spec Care Dentist of illness in the aged: the index of ADL—a standardized measure of
2005;25(2):96-105. biological and psychosocial function. JAMA 1963;185:914-919.
17. Ellefsen B, Holm-Pedersen P, Morse DE, Schroll M, Andersen BB, 27. Clark CM, Sheppard L, Fillenbaum CG, et al. Variability in
Waldemar G. Caries prevalence in older persons with and without annual Mini-Mental State Examination score in patients with probable
dementia. J Am Geriatr Soc 2008;56(1):59-67. Alzheimer disease: a clinical perspective of data from the Consortium
18. Folstein MF, Folstein SE, McHugh PR. “Mini-mental state”: a to Establish a Registry for Alzheimer’s Disease. Arch Neurol 1999;
practical method for grading the cognitive state of patients for the clini- 56(7):857-862.
cian. J Psychiatr Res 1975;12(3):189-198. 28. Jones RW, Soininen H, Hager K, et al. A multinational, ran-
19. World Health Organization. ICD-10: The International Classifica- domised, 12-week study comparing the effects of donepezil and galanta-
tion of Diseases and Related Health Problems, 10th revision. Geneva: mine in patients with mild to moderate Alzheimer’s disease. Int J
World Health Organization; 1992. Geriatr Psychiatry 2004;19(1):58-67.
20. National Institute of Dental Research, Epidemiology and Oral 29. Loy C, Schneider L. Galantamine for Alzheimer’s disease and
Disease Prevention Program. Oral health of United States adults: the mild cognitive impairment. Cochrane Database Syst Rev 2006;(1):