Pattern of Tooth loss in Older Adults
with Dementia Under Current Model of
Care
Xi Chen, DDS, PhD
Assistant Professor
Department of Dental Ecology
4/13/2015
Xi Chen, UNC School of Dentistry
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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
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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
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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 .
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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
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• Increased denture- related
soft tissue problems
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Oral Health Issues in Older Adults
with Dementia
• Increased prevalence of soft tissue lesions
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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
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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
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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)
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Methods
• Determination of enrollment period
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Methods
• Data collection
– Two sources
• Dental office management system
• Dental records
– 27 variables were identified and used as predictors
•
•
•
•
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Demographics
Baseline medical assessment
Baseline cognitive and functional assessment
Baseline oral assessment
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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.
Dementia
Age
Tooth Loss
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Methods
• Addressing potential confounders
– Propensity Score Matching
 P(dem ented) 
  1 1   2  2   3  3     p  p
In 
 P(non  dem ented) 
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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
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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
25.2
Female
70.4
74.8
Dental
insurance
No
33.1
15.1
Yes
66.9
84.9
Residential
status
Community
65.6
10.1
Assisted living
9.4
4.2
Nursing home
25.0
85.7
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Xi Chen, UNC School of Dentistry
0.3592
0.0002
<.0001
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Results
Dental 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
None
1.2
0.9
Small to
moderate
85.5
67.9
High
13.3
31.3
No
65.6
67.2
Yes
34.4
32.8
Calculus / Plaque /
Gingival bleeding
(%)
Use of prosthesis
at arrival (%)
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<.0001
0.7431
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Results
Medical 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
0
39.7
18.1
1
37.0
56.0
2
7.6
9.5
3
15.8
16.4
Maximum of ADS * of
current medications
(%)
0.0002
* ADS – Anticholinergic Drug Scale
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Results
Cognitive and functional assessment
Cognitive
impairment
(%)
Physical
mobility (%)
Non-demented
Group (N=372)
Demented
Group (N=119)
None
82.9
2.5
Questionable
4.1
0.9
Slight
8.7
43.2
Moderate to severe
4.4
53.4
Walk independently
66.5
17.1
Need walker
19.2
30.8
Need help in
transfer
14.3
51.3
0
0.9
Self sufficient
84.0
21.0
Need help
16.0
74.0
0
5.0
Bedridden
Capacity to
perform oral
hygiene (%)
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Won’t cooperate
Xi Chen, UNC School of Dentistry
P value
<0.0001
<0.0001
<0.0001
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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
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Results
Tooth survival
Time
Percent 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
P = 0.50; Hazard Ratio = 0.92 for demented vs. non-demented subjects with 95% confidence interval (0.59, 1.63)
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Results
Rate of tooth loss events per patient year
Rate of tooth loss per 100
patient-year (SE)
Demented group
Non-demented group
14.9 (2.04)
95% confidence
interval
P Value
(11.4, 19.5)
0.9943
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)
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Results
Number of teeth lost per patient per 5 years
Number of teeth lost per
patient per 5 years (SE)
Demented group
Non-demented group
1.21 (0.25)
95% confidence
interval
P Value
(0.80, 1.82)
0.4764
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)
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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
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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)
–
–
–
–
–
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non-restorability (53.8%)
dental caries (45.6%)
periodontal disease (40.3%)
prosthetic considerations (45.6%)
non-dental factors (13-17%)
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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
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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
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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
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