Prevention of tooth loss and dental pain for reducing the global burden of oral diseases

FDI World Dental CongressOral Health for an Ageing PopulationPoznan, Poland September 7-10, 2016

Susan Hyde, DDS, MPH, PhDSophie Dartevelle, DDSVeronique Dupuis, DDS, PhDBoipelo P. Mariri, DDS, MS

September 10, 2016

Outline

• Life course approach• Global burden of oral diseases

– Community-dwelling

– Homebound and long-term care residents

• Disease models, risk assessment• Effectiveness, cost analysis, and

recommendations for preventive interventions– Seattle Care Pathway

– Alternative models of care

– Interprofessional opportunities

• Oral health policy

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Thomson et al. Community Dent Oral Epidemiol. 2004

Centers for Disease Control and Prevention. USDHHS 2013.

Life-course Approach to Oral Health

• Caries and periodontal disease are chronic conditions, highly prevalent, largely irreversible, and cumulative in nature

– Social inequities follow the life course

– Unconscious bias affects oral health and treatment

• Older adults present with wide-ranging clinical needs and levels of wellbeing

– Two-thirds of older Americans have multiple chronic diseases

– Functional limitation decreases the ability for self-care

– Polarized delivery of dental care during the last year of lifeChen et al. J Am

Dent Assoc 2013.

Global Burden Untreated Caries = 35%

4Image = http://www.map-menu.com/

47%

20%

21%19% coronal14% root

Age-standardizedKassebaum et al. J Dent Res 2015.

Global Burden Severe Periodontitis = 11%

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10%51%

19%

Aged 65+ yearsKassebaum et al. J Dent Res 2014.

Global Burden Severe Tooth Loss = 2.3%

6Image = http://www.map-menu.com/

Aged 65+ years

30%

9%19%Average

19 teeth

Kassebaum et al. J Dent Res 2014.

Global Burden Oral Diseases

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Oral Conditions Combined = 15 million DALYsAverage Health Loss = 224 years/100,000 populationEconomic Burden = $USD442 billion

Marcenes 2013.

Listl 2015.

Frail Older Adults• Oral disease estimates of homebound adults

– Poor oral health (79% caries), high unmet need (34% pain) and preference for in-home dental services (94%)

• Oral disease estimates in long-term care– 59% of dentate have untreated caries (34% major-urgent

treatment needs), 74% gingivitis

– 50% of edentulous don’t have dentures

• Assessment, daily oral care, and referral– Assessment = 78% performed by nurses

– Daily oral hygiene = 25% missing products, 16% received assistance

– Barriers to care = shortage of dental professionals, complexity of patient and environment, cost of dental care, insurance status, and low reimbursement

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MA Dept Pub Health Office of Oral Health 2010.

Dharamsi et al. J Dent Educ 2009.

Coleman and Watson. J Am Geriatr Soc 2006.

Ornstein et al. J Am Geriatr Soc 2015.

Multifactorial Model Dental Caries

9Image = http://www.nap.edu/read/13086/chapter/4

Fisher-Owens et al. Pediatrics 2007.

Caries RiskAssessment

Featherstone et al. J Calif Dent Assoc 2007.

Root Caries Aged 65+

1100ppm F Toothpaste

F-Triclosan Toothpaste

F-ACP Toothpaste

5000ppm F Toothpaste

225-900ppm F Rinse

NaF Varnish Chlorhexi-dineVarnish

Silver Diamine F

Prevention 67% 90% 98%   MD = -0.1836%

56-64% MD = -0.6741-57%

MD = -0.3372%

Arrest       RR = 0.4952-82%

  54-92%   MD = -0.2490% 

Cost/Year  $36 $48 $72  $365 $64 $7 $12 $1

ACP = amorphous calcium phosphateBold = meta-analysis; otherwise randomized clinical trialMD = mean difference; RR = relative risk

Li 2016, Wierichs 2015, Gluzman 2013, Zhang 2013, Tan 2010.

Root Caries Prevention Recommendations• Community-dwelling older adults: triclosan-

fluoride or amorphous calcium phosphate-fluoride toothpaste

• Frail older adults: 5000ppm fluoride toothpaste and quarterly-application of chlorhexidine/fluoride varnish or yearly silver diamine fluoride is effective to decrease progression and initiation of root caries

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Gluzman et al. Spec Care Dent 2013.

Wierichs et al. J Dent Res 2015.

Gluzman et al. Spec Care Dent 2013.

Multifactorial Model Periodontitis

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Mariotti and Hefti. BMC Oral Health 2015.

14Image = https://perioprosthocc.wordpress.com/2015/10/16/periodontal-risk-assessment-pra-in-clinical-case-reviews-and-results/

Periodontal Risk Assessment

Lang, Tonetti. Oral Health Prev Dent 2003.

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  Prophylaxis q3 vs 12 Months

Powered Toothbrush

Add Interdental Brushing/Floss

Triclosan Toothpaste

Chlorhexidine Rinse

Essential Oils Rinse (Listerine)

Plaque Index MD = -0.15 MD = -0.47 (21%)

MD = -0.95 (32%)

MD = -0.47 (22%)

MD = -0.68 (33%)

MD = -0.39

Gingivitis Index

MD = -0.21 MD = -0.21 (11%)

MD = -0.53 (34%)

MD = -0.27 (22%)

MD = -0.24 (26%)

MD = -0.36

Bleeding Index

      MD = -0.13 (48%)

MD = -0.21  

Attachment Loss

     Not significant

   

Tooth Loss        Not significant

 

Cost/Year $320 $50 $32 $48 $342 $58

Bold = meta-analysis; otherwise randomized clinical trialMD = mean difference

Periodontitis Prevention: Effectiveness and Cost Analysis

Van Leeuwen 2014, Yaacob 2014, Poklepovic 2013, Riley 2013, Worthington 2013, Van Strydonck 2012, Wyatt 2007.

Periodontitis Prevention Recommendations• Daily oral hygiene more effective for removing

plaque and preventing gingivitis than periodic prophylaxis

– Powered toothbrushes, interdental brushes or floss, triclosan toothpaste, chlorhexidine, and Listerine provide adjunctive plaque control

– Repeated and tailored oral hygiene instruction is key

• Interventions which reduce plaque and gingivitis do not translate into preventing periodontitis or tooth loss

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Matthews 2014.

Van Leeuwen 2014, Yaacob 2014, Poklepovic 2013, Riley 2013, Van Strydonck 2012.

Tonetti 2015.

Riley 2013, Wayatt 2007.

  No Dependency Pre Dependency Low Dependency Medium Dependency

High Dependency

Description Fit, exercises regularly

Well-controlled chronic disease

Chronic disease affects oral health, independent

Chronic disease, ADL dependency, home-bound

Complex medical management, long-term care

Assessment Oral health risk assessments

Salivary flow Cause of increasing dependency

Polypharmacy, ability to tolerate treatment

Medical, pharmacy, diet assessments

Prevention 1100ppm F paste Powered brush, F rinse

5000ppm F paste, F varnish

Recall q3 months, chlorhexidine

Silver diamine fluoride

Treatment Full range of treatment options

Plan easy maintenance treatment with long-term viability

Repair/replace strategic teeth to maintain shortened arch

Maintain shortened dental arch, F-releasing restorations, ART

Palliative care

Communication Oral hygiene instructions

Oral:systemic health connections

↑ dependency = ↑ oral health risk

Health care team, caregivers

Director of Nursing, family, caregivers

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Pretty et al.Gerodontology 2014

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Alternative Models of Care

Small Private Group Practice Large Corporate/Non-Profit

Solo Cooperative Collaborative Interprofessional

Business Model

Practitioner OrganizationMertz, Wides. Oral Health Workforce Research Center 2015.

Interprofessional Opportunities

• Prevention– Common risk factor approach

• Collaborative care model– Diabetes toolkit for pharmacy, podiatry, optometry,

and dentistry

• Long-term care– Increased presence of dental providers

– Training care providers in assessment and daily oral care

MA Dept Pub Health Office of Oral Health 2010.

http://www.cdc.gov/diabetes/ndep/toolkits/ppod.html

Image = https://interprofessional.ucsf.edu

Watt. Community Dent Oral Epidemiol 2007.

Oral Health Policy Approaches

Watt. Community Dent Oral Epidemiol 2007.

Summary

• Untreated caries, periodontitis, and tooth loss are prevalent among older adults

– Caries prevention treatments shown to reduce new lesions

– Periodontitis prevention treatments not shown to reduce attachment loss or tooth loss

• Assessment, prevention, treatment, and communication must be provided appropriate to the level of dependency

– Chronic disease prevention and management can benefit from interprofessional collaboration

• Evidence-based practice needs to inform oral health policy

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