Pattern of Tooth loss in Older Adults with Dementia Under Current Model of Care Xi Chen, DDS, PhD Assistant Professor Department of Dental Ecology 5/2/20151Xi Chen, UNC School of Dentistry

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 5/2/2015Xi Chen, UNC School of Dentistry2

5/2/2015Xi Chen, UNC School of Dentistry3 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

5/2/2015Xi Chen, UNC School of Dentistry4 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.

Oral Health Issues in Older Adults with Dementia Increased prevalence of edentulism 5/2/2015Xi Chen, UNC School of Dentistry5

Oral Health Issues in Older Adults with Dementia Decreased use of dentures over time Increased denture- related soft tissue problems 5/2/2015Xi Chen, UNC School of Dentistry6

Oral Health Issues in Older Adults with Dementia Increased prevalence of soft tissue lesions 5/2/20157Xi Chen, UNC School of Dentistry

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 5/2/20158Xi Chen, UNC School of Dentistry

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 5/2/20159Xi Chen, UNC School of Dentistry

5/2/2015Xi Chen, UNC School of Dentistry10 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

5/2/2015Xi Chen, UNC School of Dentistry11 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, or Without ICD-9 code – Dementia (all types) – Alzheimer’s disease – Chronic Brain Syndrome (CBS) – Sampling process Two study groups Propensity Score Matching (PSM)

5/2/2015Xi Chen, UNC School of Dentistry12 Methods Determination of enrollment period

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 5/2/201513Xi Chen, UNC School of Dentistry

5/2/2015Xi Chen, UNC School of Dentistry14 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

5/2/2015Xi Chen, UNC School of Dentistry15 Methods Addressing potential confounders – Age – Residential status – Anticholinergic effect of medication – Physical mobility etc. Tooth Loss AgeDementia

5/2/2015Xi Chen, UNC School of Dentistry16 Methods Addressing potential confounders – Propensity Score Matching

5/2/2015Xi Chen, UNC School of Dentistry17 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

Results Demographic characteristics of study subjects Non-demented Group (N=372) Demented Group (N=119) P value Length of enrollment Age at enrollment <.0001 GenderMale Female Dental insurance No Yes Residential status Community <.0001 Assisted living Nursing home /2/201518Xi Chen, UNC School of Dentistry

Results Dental assessment at first arrival Non-demented Group (N=372) Demented Group (N=119) P value Number of remaining teeth Number of decayed/broken teeth Number of teeth with restoration Percent of decayed/broken teeth among the remaining teeth Percent of filled teeth among the remaining teeth Calculus / Plaque / Gingival bleeding (%) None <.0001 Small to moderate High Use of prosthesis at arrival (%) No Yes /2/201519Xi Chen, UNC School of Dentistry

Results Medical assessment Non-demented Group (N=372) Demented Group (N=119) P value Number of medical conditions <.0001 Burden of comorbidity (Charlson comorbidity index) <.0001 Number of medications Sum of ADS * of current medications Maximum of ADS * of current medications (%) * ADS – Anticholinergic Drug Scale 5/2/201520Xi Chen, UNC School of Dentistry

Results Cognitive and functional assessment Non-demented Group (N=372) Demented Group (N=119) P value Cognitive impairment (%) None < Questionable Slight Moderate to severe Physical mobility (%) Walk independently < Need walker Need help in transfer Bedridden 00.9 Capacity to perform oral hygiene (%) Self sufficient < Need help Won’t cooperate /2/201521Xi Chen, UNC School of Dentistry

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 Mean number of teeth lost among the subjects with tooth loss events /2/201522Xi Chen, UNC School of Dentistry

Results Time Percent with tooth loss event Non-dementedDemented 12 m m m m m Tooth survival P = 0.50; Hazard Ratio = 0.92 for demented vs. non-demented subjects with 95% confidence interval (0.59, 1.63) 5/2/201523Xi Chen, UNC School of Dentistry

Results Rate of tooth loss events per patient year Rate of tooth loss per 100 patient-year (SE) 95% confidence interval P Value Demented group 14.9 (2.04)(11.4, 19.5) Non-demented group 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) 5/2/201524Xi Chen, UNC School of Dentistry

Results Number of teeth lost per patient per 5 years Number of teeth lost per patient per 5 years (SE) 95% confidence interval P Value Demented group 1.21 (0.25)(0.80, 1.82) Non-demented group 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) 5/2/201525Xi Chen, UNC School of Dentistry

5/2/2015Xi Chen, UNC School of Dentistry26 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

5/2/2015Xi Chen, UNC School of Dentistry27 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

5/2/2015Xi Chen, UNC School of Dentistry28 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%)

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 5/2/201529Xi Chen, UNC School of Dentistry

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 5/2/201530Xi Chen, UNC School of Dentistry

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 5/2/201531Xi Chen, UNC School of Dentistry