Two-year survival of ART restorations placed in elderly patients: A randomised controlled clinical trial

OBJECTIVES: Older dentate adults are a high caries risk group who could potentially benefit from the use of the atraumatic restorative treatment (ART). This study aimed to compare the survival of ART and a conventional restorative technique (CT) using rotary instruments and a resin-modified glass-ionomer for restoring carious lesions as part of a preventive and restorative programme for older adults after 2 years.

METHODS: In this randomised controlled clinical trial, 99 independently living adults (65-90 years) with carious lesions were randomly allocated to receive either ART or conventional restorations. The survival of restorations was assessed by an independent and blinded examiner 6 months, 1 year and 2 years after restoration placement.

RESULTS: Ninety-six (67.6%) and 121 (76.6%) restorations were assessed in the ART and CT groups, respectively, after 2 years. The cumulative restoration survival percentages after 2 years were 85.4% in the ART and 90.9% in the CT group. No statistically significant between group differences were detected (p=0.2050, logistic regression analysis).

CONCLUSIONS: In terms of restoration survival, ART was as effective as a conventional restorative approach to treat older adults after 2 years. This technique could be a useful tool to provide dental care for older adults particularly in the non-clinical setting. (Trial Registration number: ISRCTN 76299321).

CLINICAL SIGNIFICANCE: The results of this study show that ART presented survival rates similar to conventional restorations in older adults. ART appears to be a cost-effective way to provide dental care to elderly patients, particularly in out of surgery facilities, such as nursing homes.

Cost-effectiveness of ART restorations in elderly adults: a randomized clinical trial

BACKGROUND: As the world population ages, the requirement for cost-effective methods of treating chronic disease conditions increases. In terms of oral health, there is a rapidly increasing number of dentate elderly with a high burden of maintenance. Population surveys indicate that older individuals are keeping their teeth for longer and are a higher caries risk group. Atraumatic Restorative Treatment (ART) could be suitable for patients in nursing homes or house-bound elderly, but very little research has been done on its use in adults.

OBJECTIVES: To compare the cost-effectiveness of ART and a conventional technique (CT) for restoring carious lesions as part of a preventive and restorative programme for older adults.

METHODS: In this randomized clinical trial, 82 patients with carious lesions were randomly allocated to receive either ART or conventional restorations. Treatment costs were measured based on treatment time, materials and labour. For the ART group, the cost of care provided by a dentist was also compared to the cost of having a hygienist to provide treatment. Effectiveness was measured using percentage of restorations that survived after a year.

RESULTS: Eighty-two patients received 260 restorations, that is, 128 ART and 132 conventional restorations. 91.1% of the restorations were on one surface only. After a year, 252 restorations were assessed in 80 patients. The average cost for ART and conventional restorations was €16.86 and €28.71 respectively; the restoration survival percentages were 91.1% and 97.7%, respectively. This resulted in a cost-effectiveness ratio of 0.18 (ART) and 0.29 (CT). When the cost of a hygienist to provide ART was inserted in the analysis, the resulting ratio was 0.14.

CONCLUSIONS: Atraumatic restorative treatment was found to be a more cost-effective alternative to treat older adults after 1 year, compared to conventional restorations, especially in out of surgery facilities and using alternative workforce such as hygienists. Atraumatic restorative treatment can be a useful tool to provide dental care for frail and fearful individuals who might not access dental treatment routinely.

Content and methodology of predoctoral Geriatric Dentistry teaching in Europe

Objectives: To explore the content and methodology of predoctoral Geriatric Dentistry teaching amongst European dental schools.
Methods: The study was conducted by the European College of Gerodontology (ECG) Education Committee. Αn electronic questionnaire has been developed with close and open-ended items, including information on the prevalence and institutional anchorage of Gerodontology programs, the educators, the content and the methodology of teaching. An electronic mail, including a hyperlink to the questionnaire, was sent to 216 dental schools in 39 European countries (Winter/ Spring 2016). The Deans were asked to either answer themselves, or forward the link to faculty members with knowledge on Gerodontology teaching at their respective schools. Repeated reminders or telephone calls were used for non-respondents and personal networks were exploited to identify potential contact persons.
Results: Until August 2016, 121 dental schools from 29 countries responded to the survey (response rate 56%, EU response rate: 60%). Gerodontology was included in the predoctoral curricula of 86% of the respondents and was compulsory in 68%. The course was mainly offered in senior students and was interdisciplinary in 30% of the schools, delivered mainly by dentists (79%), physicians (21%), psychologists (10%), and nurses (5%). It was conducted as an independent lecture series in 40% of the schools and a course director was assigned in 44% of the respondents. When embedded in other disciplines, these were mainly Prosthodontics (31%). The content included a large number of items, such as epidemiology of oral health, medical problems in old age, prosthodontic management, xerostomia, and caries risk assessment. Lectures were the most common teaching format (69%), followed by small group seminars (27%). The most common types of educational material used were scientific articles (48%), printed textbooks (44%), lecture notes (40%) and e-learning material (21%). Clinical training was offered by 64% of the respondents, within the dental school clinics (49%) and/or in outreach locations (40%).
Conclusion: Amongst the respondent European dental schools (66%) there is an increasing number that teach Gerodontology at a pre-doctoral level with significant variations in content and methodology. Official guidelines and the dissemination of the ECG pre-doctoral curriculum guidelines might help to increase the prevalence and improve the status of Gerodontology teaching in Europe.

Minimal intervention dentistry and older patients Part 1: Risk assessment and caries prevention

Ten million people in the UK today are aged over 65. The latest projections estimate that there will be 5 1/2 million more people aged 65 and older in the next 20 years. This projected pattern of population ageing will have profound consequences for dentistry. Minimal intervention dentistry (MID) is a modern evidence-based approach to caries management in dentate patients that uses the 'medical model' whereby disease is controlled by the 'oral physician'. This approach offers considerable benefits over conventional dentistry for older patients. It encourages patients to be responsible for their oral health through the provision of both knowledge and motivation. MID encompasses risk assessment for dental disease, early detection and control of disease processes, and minimally invasive treatment. 

Clinical Relevance: Risk assessment tools can aid the general dental practitioner and the patient to develop a suitable caries prevention programme for that individual and reduce the need for future operative intervention.

Caries and the older patient

Ageing of the population, together with prolonged retention of teeth, has brought new challenges to dentistry. Whereas in the past oral care for the elderly was restricted to provision of dentures, older patients are now presenting with dental caries and failed restorations. These problems may have an impact on their general health and quality of life. Poor oral hygiene, xerostomia and diet are among the risk factors for caries in older patients and need to be addressed in order to achieve control of the disease. Carious lesions can be treated conservatively in many cases or may need surgical management.

CLINICAL RELEVANCE: Caries is an oral health issue among older patients and can result in tooth loss. Oral health has a great impact on general health and quality of life of elderly people.

Risk indicators associated with root decay in independently living older adults

Objective: To determine the risk indicators associated with root caries experience in a cohort of independently living older adults in Ireland.
Methods: The data reported in the present study were obtained from a prospective longitudinal study conducted on the risk factors associated with root caries incidence in a cohort of independently living older adults (n=334). Each subject underwent an oral examination, performed by a single calibrated examiner, to determine the root caries index and other clinical variables. Questionnaires were used to collect data on oral hygiene habits, diet, smoking and alcohol habits and education level. A regression analysis with the outcome variable of root caries experience (no/yes) was conducted.
Results: A total of 334 older adults with a mean age of 69.1 years were examined. 53.3% had at least one filled or decayed root surface. The median root caries index was 3.13 (IQR 0.00, 13.92). The results from the multivariate regression analysis indicated that individuals with poor plaque control (OR 9.59, 95%CI 3.84-24.00), xerostomia (OR 18.49, 95%CI 2.00-172.80), two or more teeth with coronal decay (OR 4.50, 95% CI 2.02-10.02) and 37 or more exposed root surfaces (OR 5.48, 95% CI 2.49-12.01) were more likely to have been affected by root caries.
Conclusions: The prevalence of root caries was high in this cohort. This study suggests a correlation between root caries and the variables poor plaque control, xerostomia, coronal decay (≥2 teeth affected) and exposed root surfaces (≥37). The significance of these risk indicators and the resulting prediction model should be further evaluated in a prospective study of root caries incidence.
Clinical Significance: Identification of risk indicators for root caries in independently living older adults would facilitate dental practitioners to identify those who would benefit most from interventions aimed at prevention.