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

1. Pattern of Tooth loss in Older Adults with Dementia Under Current Model of Care Xi Chen, DDS, PhD Assistant Professor Department of Dental Ecology Xi Chen, UNC School of Dentistry

2. 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 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 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 . Xi Chen, UNC School of Dentistry

5. Oral Health Issues in Older Adults with Dementia • Increased prevalence of edentulism Xi Chen, UNC School of Dentistry

6. Oral Health Issues in Older Adults with Dementia • Decreased use of dentures over time • Increased denture- related soft tissue problems Xi Chen, UNC School of Dentistry

7. Oral Health Issues in Older Adults with Dementia • Increased prevalence of soft tissue lesions Xi Chen, UNC School of Dentistry

8. 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 Xi Chen, UNC School of Dentistry

9. 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 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 Xi Chen, UNC School of Dentistry

11. 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) Xi Chen, UNC School of Dentistry

12. Methods • Determination of enrollment period Xi Chen, UNC School of Dentistry

13. 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 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 Xi Chen, UNC School of Dentistry

15. Methods • Addressing potential confounders • Age • Residential status • Anticholinergic effect of medication • Physical mobility etc. Dementia Age Tooth Loss Xi Chen, UNC School of Dentistry

16. Methods • Addressing potential confounders • Propensity Score Matching 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 Xi Chen, UNC School of Dentistry

18. Results Demographic characteristics of study subjects Xi Chen, UNC School of Dentistry

19. Results Dental assessment at first arrival Xi Chen, UNC School of Dentistry

20. Results Medical assessment * ADS – Anticholinergic Drug Scale Xi Chen, UNC School of Dentistry

21. Results Cognitive and functional assessment Xi Chen, UNC School of Dentistry

22. Results Characteristics of tooth loss between demented group and non-demented group Xi Chen, UNC School of Dentistry

23. Results Tooth survival P = 0.50;Hazard Ratio = 0.92 for demented vs. non-demented subjects with 95% confidence interval (0.59, 1.63) Xi Chen, UNC School of Dentistry

24. Results Rate of tooth loss events per patient year Ratio of tooth loss events for demented and non-demented subjects = 0.93, with 95% confidence interval (0.62, 1.39) Xi Chen, UNC School of Dentistry

25. Results Number of teeth lost per patient per 5 years 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) Xi Chen, UNC School of Dentistry

26. 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 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 Xi Chen, UNC School of Dentistry

28. 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%) Xi Chen, UNC School of Dentistry

29. 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 Xi Chen, UNC School of Dentistry

30. 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 Xi Chen, UNC School of Dentistry

31. 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 Xi Chen, UNC School of Dentistry