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Assessing Caries Increments in Elderly

Patients With and Without Dementia: A


One-Year Follow-up Study
Birita Ellefsen, Poul Holm-Pedersen, Douglas E.
Morse, Marianne Schroll, Birgitte Bo Andersen
and Gunhild Waldemar
J Am Dent Assoc 2009;140;1392-1400

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R E S E A R C H

Assessing caries increments in elderly


patients with and without dementia
A one-year follow-up study
Birita Ellefsen, DDS, PhD; Poul Holm-Pedersen, DDS, DrOdont; Douglas E. Morse, DDS, PhD;
Marianne Schroll, MD, DMSCc; Birgitte Bo Andersen, MD, DMSc; Gunhild Waldemar, MD, DMSc

ew studies have exam-

F
D
ined the oral health of
elderly people with
ABSTRACT ✷
J
A A


®
dementia.1,2 The majority

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Background. The authors conducted a study to

N
CON

IO
of these are cross- determine one-year coronal and root caries increments

T
sectional surveys, with some

A
in patients newly diagnosed as having Alzheimer N

I
U C
IN U
addressing only overall dental and disease (AD), other dementia (OD) or no dementia. A G ED
4
RT
denture status,3,4 others reporting Methods. The authors recruited patients from two hos- ICLE
findings regarding carious teeth or pital memory clinics in Copenhagen. The oral examination included an
decayed, missing or filled teeth assessment of dental status and dental caries. The authors used a struc-
(DMFT)5-7 and a small number tured questionnaire to obtain information regarding demographic, social and
reporting results at the tooth- functional variables.
surface level.4,8-10 However, few Results. In the baseline study, 106 dentate patients participated. Of these,
longitudinal studies have investi- 77 completed the follow-up study. The participants’ mean age was 81.9 years
gated the relationship between de- at baseline and 82.5 years at follow-up. At baseline, 87 (82 percent) of 106
mentia and caries incidence and participants had dementia and at follow-up, 64 (83 percent) of 77 partici-
increments over time.11-14 pants had dementia. The mean number of decayed tooth surfaces was signif-
Jones and colleagues13 found icantly higher at follow-up than at baseline for all participants, and the
that male patients with Alz- number was highest for the OD group. The one-year adjusted caries and
heimer disease (AD) tended to filling increments (ADJCIs) were high for participants with and without
have higher mean increments dementia but were highest for participants in the AD and OD groups. Base-
(that is, the number of new sur- line risk factors for developing elevated coronal and root ADJCIs included
faces with caries at follow-up) of having caries, having many teeth and being older than 80 years.
coronal and root caries than did Conclusions. Elderly people referred to a memory clinic were at an ele-
control subjects without demen- vated risk of developing high levels of coronal and root-surface caries during
tia. In another longitudinal study, the first year after referral, and those with a dementia diagnosis other than
Ship and Puckett14 reported that AD appeared to be at a particularly high risk of developing multiple carious
patients with AD had notably lesions during the first year after diagnosis.
higher DMFT scores and a Clinical Implications. These findings underscore the importance of
greater number of filled coronal addressing the oral health needs of elderly people suspected of having expe-
and cervical surfaces than did rienced cognitive decline.
control subjects without demen- Key Words. Alzheimer disease; caries; dental care for elderly patients;
tia; however, the longitudinal nursing homes; oral health; research.
changes were not statistically dif- JADA 2009;140(11):1392-1400.
ferent between the two groups. In
Dr. Ellefsen is an assistant professor, Copenhagen Gerontological Oral Health Research Center, School of Dentistry, University of Copenhagen, Norre Allé 20,
Copenhagen DK-2200 CPH N, Denmark, e-mail “bel@odont.ku.dk”. Address reprint requests to Dr. Ellefsen.
Dr. Holm-Pedersen is a professor, Copenhagen Gerontological Oral Health Research Center, School of Dentistry, University of Copenhagen.
Dr. Morse is an associate professor, Department of Epidemiology and Health Promotion, New York University, College of Dentistry, New York City.
Dr. Schroll is a professor, Department of Geriatric Medicine, Bispebjerg University Hospital, Copenhagen.
Dr. Andersen is a consultant neurologist, Memory Disorders Research Group, Department of Neurology, Copenhagen University Hospital, Rigshospitalet.
Dr. Waldemar is a professor, Memory Disorders Research Group, Department of Neurology, Copenhagen University Hospital, Rigshospitalet.

1392 JADA, Vol. 140 http://jada.ada.org November 2009


Copyright © 2009 American Dental Association. All rights reserved. Reprinted by permission.
R E S E A R C H

these two studies, small sample sizes may have eases, 10th Revision.19
precluded the detection of statistically significant Both the baseline and one-year follow-up oral
differences in caries incidence and increments examinations were conducted by the same dentist
between participants with AD and control sub- (B.E.) in the participants’ homes with the use of a
jects without dementia. mobile dental unit that included a fiber optic
Chalmers and colleagues11 followed up a larger light, suction and an air-water syringe. The den-
group of community-dwelling older adults across tist performed the examinations according to
a one-year period and found that the incidence National Institute of Dental Research20 criteria
and increments of coronal and root caries were for coronal and root decayed surfaces (DSs) and
significantly higher among older adults with filled surfaces (FSs). The dentist recorded coronal
dementia than among those without dementia. caries and restorations for five surfaces on molars
The results of their study were in agreement with and premolars and for four surfaces on canines
those of other studies, which showed that caries and incisors. She recorded root caries and restora-
experience was related to dementia severity but tions for four surfaces on each tooth. We defined
not to a specific dementia diagnosis.9-11,13,15,16 gingival recession as being present if 1 millimeter
In a recent study of people referred to memory or more of the root surface was visible below the

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clinics in Copenhagen, we17 found that older cementoenamel junction. We excluded teeth from
adults (that is, 65 years and older) with newly the follow-up study that were not examined at
diagnosed dementia had significantly higher baseline. We excluded a tooth surface if it was not
levels of coronal and root caries compared with accessible for examination owing to a lack of
older adults who did not fulfill the criteria for a patient cooperation or excessive debris, plaque or
dementia diagnosis at the dementia assessment. calculus. We used a structured questionnaire to
In contrast to previous studies, we found that obtain information about demographic, social and
older adults with a new clinical diagnosis of AD functional variables.
had significantly higher levels of caries compared At the baseline examination, the dentist asked
with participants who had a dementia diagnosis all participants if they would be willing to partici-
other than AD, suggesting that caries severity is pate in a follow-up oral examination 12 months
related to dementia type. later. For those who were unable to give informed
After this initial cross-sectional study of caries consent at baseline (because of dementia), the
prevalence in people referred to memory clinics, clinician asked relatives or caregivers to provide
we conducted a one-year follow-up assessment of written permission. At the baseline examination,
these study participants. The aim of this report is all participants or their caregivers agreed to join
to present the one-year longitudinal findings the follow-up study.
regarding coronal and root caries increments Twelve months (or as close as possible) after
among participants in the follow-up study. the baseline examination, the dentist or a dental
assistant contacted the study participants and/or
PARTICIPANTS, MATERIALS AND their relatives or caregivers to schedule a follow-
METHODS
up oral examination appointment. The appoint-
The baseline study population consisted of people ment was confirmed by telephone on the sched-
referred to the memory clinics of Rigshospitalet uled day. The follow-up examination included a
and Bispebjerg hospitals in Copenhagen. From clinical oral examination, an oral interview and
2002 to 2004, a clinic physician (B.B.A., G.W. or administration of the MMSE.18
others) or a nurse at the participating hospitals
recruited participants into the study. Details con-
cerning the dementia diagnostic program have ABBREVIATION KEY. AD: Alzheimer disease.
ADJCIs: Adjusted caries and filling increments. ADL:
been reported elsewhere.17 Briefly, a team of geri-
Activities of daily living. CCIs: Crude caries and filling
atricians, neurologists or both carried out the increments. DFSs: Decayed and filled surfaces. DMFT:
assessment of dementia at the memory clinics. Decayed, missing and filled teeth. DSs: Decayed sur-
The assessments consisted of a series of medical faces. FSs: Filled surfaces. IADL: Instrumental Activi-
and mental state examinations, including the ties of Daily Living. MMSE: Mini-Mental State Exami-
Mini-Mental State Examination (MMSE),18 and nation. MOB: Mobility. MOB-H: Mobility-help.
the physicians diagnosed dementia according to MOB-T: Mobility-tired. NCIs: Net caries and filling
criteria in the International Classification of Dis- increments. ND: No dementia. OD: Other dementia.

JADA, Vol. 140 http://jada.ada.org November 2009 1393


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R E S E A R C H

During the follow-up clinical oral examination, of a partial denture (yes versus no) and number of
which was performed in the same manner as the medications (≤ three versus > three), as well as
baseline examination, the dentist collected infor- self-reported marital status, children (yes versus
mation about several clinical parameters no), MMSE scores (≥ 24 versus 0 to 23 [the lower
including dental status (that is, teeth present), the score, the greater the cognitive impairment]),
caries and periodontal status, and dental pros- housing (own versus rent versus nursing home or
thesis status. The same examiner (B.E.) con- equivalent), education (≤ seven years versus
ducted all caries assessments at baseline and > seven years), self-rated health (good versus fair-
follow-up. At all examinations, the examiner was poor), oral hygiene (toothbrushing daily versus
unaware of the dementia status of the study par- less than daily), self-rated disease (no disease
ticipants. The follow-up interview consisted of the versus any disease), dental visit habits (regularly
same questions as those administered at versus less than once a year) and xerostomia.
baseline.17 Additional covariates included mobility (MOB)
Primary outcome variables. The primary function22-24 and Instrumental Activities of Daily
outcome variables were as follows: Living (IADL).25 Items used in the MOB scale
dcrude caries and filling increments (CCIs), net include activities of daily living (ADL)26 related to

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caries and filling increments (NCIs) and adjusted mobility only, with a focus on six activities: trans-
caries and filling increments (ADJCIs). ferring (that is, moving from one location to
dmean number of DSs, FSs and decayed and another such as from the bed to a chair), walking
filled surfaces (DFSs) for total (coronal and root) indoors, going outdoors, walking outdoors in nice
surfaces, coronal surfaces and root surfaces. weather, walking outdoors in poor weather and
We determined the CCI for each participant by climbing stairs.
counting surfaces that went from sound at base- If the participant was able to perform a given
line to decayed or filled at follow-up or from filled activity, we addressed two additional dimensions:
at baseline to recurrent caries at follow-up. with or without being tired afterward (MOB-T)
We defined examiner reversals as coronal sur- and could or could not manage the activity
faces that changed from decayed or filled at base- without help (MOB-H). We dichotomized MOB,
line to sound at follow-up, and root surfaces that MOB-H and MOB-T scales as good (score of 6)
changed from decayed or filled at baseline to versus fair-poor (score of 0 to 5).22-24 IADLs
sound at follow-up or from exposed to unexposed. addressed in our study are activities known to be
We then calculated the NCI on a per-participant related to cognitive ability, such as using public
basis for coronal and root surfaces separately by transportation or the telephone, administering
subtracting the number of examiner reversals medication and handing finances.25
from the CCI. In addition, we calculated an Participants scored one point for each of the
ADJCI that adjusted the CCI for examiner rever- following IADL items they managed:
sals by taking into consideration the impact of the dusing public transportation;
participant’s baseline caries experience: dusing the telephone;
ADJCI = CCI [1 − exrev]/[exrev + x] dadministering medications;
where exrev is the number of examiner reversals dhandling finances.
and “x” is the number of decayed to decayed/filled We then dichotomized the results (score, 0 to 2
surfaces or filled to filled surfaces.21 We then cal- versus 3 or 4). We did not obtain information
culated group means for CCIs, NCIs and ADJCIs. about smoking and usual diet.
Primary determinant variables. The diag- Statistical analysis. We conducted all statis-
nostic classification of dementia included AD tical analyses by using statistical software (SPSS
diagnosis versus other dementia (OD) diagnosis for Windows, versions 12.0 and 13.0, SPSS,
versus no dementia (ND). The OD group included Chicago). We used the χ2 test to test for differ-
patients with vascular, Lewy body, mixed, fron- ences in proportions. In addition, we used Stu-
totemporal and uncertain dementia. dent and paired t tests, as well as analysis of vari-
Covariates. Participant baseline characteris- ance (with a Tukey Honestly Significant
tics included age (≤ 80 years versus ≥ 81 years), Difference correction for multiple comparisons), to
sex, number of teeth (one through nine versus 10- compare means when the appropriate assump-
19 versus 20-32), number of decayed surfaces (0 tions were met. Otherwise, we used their non-
versus one to two versus three or more), presence parametric analogues (that is, the Mann-Whitney

1394 JADA, Vol. 140 http://jada.ada.org November 2009


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R E S E A R C H

U, Wilcoxon signed rank and Kruskal-Wallis TABLE 1


tests). We considered an α level of P < .05 (two-
tailed) to be statistically significant. We con-
Distribution of participants in
ducted logistic regression analyses to determine baseline and follow-up studies.
the association between the one-year coronal VARIABLE NO. (%) OF NO. (%) OF
PARTICIPANTS PARTICIPANTS
ADJCI (> 2 versus 0 to 2) and the independent AT BASELINE AT ONE-YEAR
variables described above. Using a backward- (N = 106) FOLLOW-UP
(n = 77*)
stepwise approach (likelihood ratio statistic
P values included in the models ≤ .20), we selected Diagnosis
Alzheimer disease 61 (57.5) 49 (63.6)
the most parsimonious model with the highest
Other dementia 26 (24.5) 15 (19.5)
percentage of correctly classified participants as No dementia 19 (18.0) 13 (16.9)
the final model. We used a similar approach when
Sex
the one-year root ADJCI (> 1 versus 0 or 1) was Male 37 (34.9) 28 (36.4)
the dependent variable of interest. Female 69 (65.1) 49 (63.6)
The ethical committees of science in Copen-
Nursing Home 25 (23.6) 26 (33.8)
hagen and Frederiksberg, Denmark, municipali-

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or Equivalent
ties approved the study design. Mean Age, Years 81.9 82.5

RESULTS * Seventy-seven (72.6 percent) of 106 participants in the baseline


study completed the follow-up study.
Baseline and follow-up
characteristics. Of the TABLE 2
106 dentate participants Mean age, MMSE* score and number of teeth at
at baseline, 77 (73 percent)
participated in the follow-
baseline and follow-up for follow-up participants
up study. Table 1 presents (n = 77).
the distribution of the 106 VARIABLE MEAN (SD†) VARIABLE AT BASELINE MEAN (SD) VARIABLE AT FOLLOW-UP
participants in the base- AD ‡ OD § ND ¶ AD OD ND
line study and the 77 par- Age, Years 82.4 (5.5) 80.1 (4.0) 78.9 (7.6) 83.6 (5.5) 81.3 (4.0) 79.9 (7.7)
ticipants in the follow-up MMSE 22.3 (3.9)A,C,a 25.4 (3.0)C 28.4 (1.8)A,b 20.4 (5.3)A,B,a 24.0 (3.4)B 26.4 (2.3)A,b
study, according to Score #**
dementia diagnosis, sex, No. of 17.3 (7.4)a 16.1 (9.0) 20.2 (8.9) 16.4 (7.8)a 15.5 (9.0) 19.5 (10.0)
institutionalization status Teeth
and age. Fourteen of the * MMSE: Mini-Mental State Examination. 18

77 follow-up participants † SD: Standard deviation.


‡ AD: Alzheimer disease.
had been institutionalized § OD: Other dementia diagnosis.
between the baseline and ¶ ND: No dementia diagnosis.
A B C
# Superscript capital letters indicate intergroup comparisons: P < .001, P < .005, P < .01, analysis of
follow-up examinations, variance, Tukey Honestly Significant Difference.
and 11 (79 percent) of ** Superscript lowercase letters indicate intragroup comparisons: P ≤ .001, P ≤ .01, paired t test.
a b

these participants had AD


(data not shown). participants with a baseline diagnosis of OD
Follow-up characteristics. The mean received a diagnosis of AD before the follow-up
number of months between the two examinations examination. One participant with an AD diag-
was 13.0 for participants with AD, 14.4 for par- nosis at baseline was declared free of dementia by
ticipants with OD and 12.4 for participants with a specialist in the memory clinic between the two
ND (Kruskal-Wallis P = .21). The results showed examinations.
no statistically significant intergroup differences Table 2 shows the mean age, MMSE score and
in the mean number of medications taken per day number of teeth at baseline and follow-up for the
(AD = 4.1, OD = 5.3 and ND = 4.3) or in the mean 77 people who participated in the one-year follow-
number of medical diagnoses other than dementia up study, according to dementia category. The
(AD = 1.8, OD = 1.9 and ND = 2.2). mean MMSE score and number of teeth de-
During the one-year follow-up period, three creased for all three groups from baseline to
participants in the ND group received a diagnosis follow-up, and the change in MMSE scores for the
of AD and one received a diagnosis of OD. Three AD and ND groups was statistically significant.

JADA, Vol. 140 http://jada.ada.org November 2009 1395


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R E S E A R C H

TABLE 3 number of DSs at follow-


up; however, the mean
Mean decayed and filled coronal and root surfaces number of DSs for the OD
at baseline and follow-up, for follow-up participants group was more than twice
(n = 77). the mean number for the
GROUP MEAN (SD*) NO. OF SURFACES AT MEAN (SD) NO. OF SURFACES AT
ND group. The mean
BASELINE FOLLOW-UP† number of DFSs for the AD
DSs ‡ FSs § DFSs ¶ DSs FSs DFSs and OD groups increased
between the baseline and
All Participants 5.7 (6.7)# 41.2 (24.2) 46.9 (25.1)# 7.9 (8.8)# 41.9 (26.0) 49.8 (28.9)#
follow-up examinations,
AD ** 6.7 (7.2) 39.5 (24.5) 46.1 (25.1)†† 8.0 (9.2) 40.3 (25.8) 48.4 (29.0)††
and the increases were sta-
OD ‡‡ 5.0 (6.6)# 38.7 (24.7) 43.7 (27.8)†† 10.2 (9.8)# 40.8 (24.6) 51.0 (28.3)†† tistically significant for
ND §§ 2.8 (3.0) 50.8 (22.1) 53.5 (22.6) 4.8 (5.1) 49.2 (28.8) 53.9 (31.0) both groups (P < .05). The
* SD: Standard deviation. mean number of DFSs for
† No statistically significant intergroup differences at follow-up for decayed surfaces, filled surfaces, or the ND group remained
decayed and filled surfaces.
relatively unchanged. We

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‡ DSs: Decayed surfaces.
§ FSs: Filled surfaces. did not observe any statis-
¶ DFSs: Decayed and filled surfaces.
# Intragroup comparisons: P ≤ .005, Wilcoxon signed rank test. tically significant inter-
** AD: Alzheimer disease. group differences in FSs or
†† Intragroup comparisons: P < .05, Wilcoxon signed rank test.
‡‡ OD: Other dementia. DFSs.
§§ ND: No dementia. Longitudinal differ-
TABLE 4
ences in oral health.
Table 4 presents the mean coronal
Mean coronal and root increments and root DFS increments. The table
for decayed and filled surfaces (DFSs), includes CCIs, NCIs and ADJCIs
according to dementia category. for all participants, according to
dementia category. All calculated
INCREMENT TYPE MEAN (SD*) CORONAL MEAN (SD) ROOT DFS increments were higher for the
DFS INCREMENTS† DFS INCREMENTS†
two dementia groups compared
AD ‡ OD § ND ¶ AD OD ND
with the ND group, although the
CCIs # 4.8 (5.4) 5.9 (4.1) 3.4 (3.2) 5.8 (5.7) 7.0 (6.5) 3.9 (4.6)
results showed no statistically sig-
NCIs ** 3.9 (5.7) 4.8 (4.4) 2.7 (3.2) 4.8 (5.6) 6.1 (7.0) 2.8 (4.3)
nificant intergroup differences.
ADJCIs †† 4.7 (5.4) 5.8 (4.0) 3.3 (3.2) 5.1 (5.3) 6.1 (6.9) 3.2 (4.0) The coronal ADJCIs were signif-
* SD: Standard deviation. icantly higher for participants
† No statistically significant intergroup differences.
‡ AD: Alzheimer disease. older than 80 years than they were
§ OD: Other dementia. for those 80 years or younger (5.5
¶ ND: No dementia.
# CCIs: Crude caries increments. versus 2.8, P = .02). The root
** NCIs: Net caries increments. ADJCIs were higher for partici-
†† ADJCIs: Adjusted caries and filling increments.
pants older than 80 years than
they were for those 80 years or
Mean MMSE scores were significantly lower for the younger, but the difference was not statistically
AD group than for the two other groups at baseline significant (5.7 versus 3.5, P = .1).
and at follow-up. The mean number of teeth was The study did not reveal any notable differ-
statistically significantly lower at follow-up than at ences in ADJCIs between participants with an
baseline for participants in the AD group. MMSE score of less than 24 and those with an
Oral health status. Table 3 presents the MMSE score of 24 or greater at follow-up. In addi-
mean number of coronal and root DSs, FSs and tion, we observed no statistically significant dif-
DFSs, according to dementia category at baseline ferences when comparing nursing home residents
and follow-up. The number of DSs was higher at with community-dwelling participants, under-
follow-up than at baseline for participants in each scoring the overall frailty of the study group.
group, but the difference was statistically signifi- Baseline predictors of impaired oral
cant for only the OD group. There were no statis- health at follow-up. Although only 77 of 106
tically significant intergroup differences in the dentate participants completed the follow-up

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R E S E A R C H

study, we conducted an exploratory analysis to TABLE 5


evaluate which baseline characteristics were
associated with coronal and root caries incre-
Baseline factors associated
ments during the one-year follow-up. with adjusted coronal caries
Coronal caries. Table 5 presents baseline fac- increments.
tors associated with the one-year coronal ADJCIs. BASELINE FACTOR*† MORE THAN 2 VERSUS
The table is based on the results of a multivariable 0-2 CORONAL CARIES
logistic regression analysis in which we used back- INCREMENTS

ward stepwise selection (P values included in the Odds 95%


Ratio ‡ Confidence
models ≤ .20), with coronal ADJCI as the dichoto- Interval
mized outcome measure (that is, 3 or more coronal
No. of Decayed Surfaces
ADJCIs versus 0 to 2) and baseline characteristics (Coronal and Root)
as independent variables. Baseline caries (coronal 0 1.00 Reference
1-2 10.02 1.24-80.96
and root) and the baseline number of teeth (20 to
3 or more 38.28 4.01-365.45
32) were strong risk factors for having 3 or more Ptrend = .002 (test of linear trend)
coronal ADJCIs, and the linear test of trend was

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No. of Teeth
highly significant for both variables. 1-9 1.00 Reference
Being older than 80 years, living in a nursing 10-19 4.53 0.79-26.12
20-32 15.51 2.68-89.84
home or its equivalent, having high IADL scores Ptrend = .003
and having a dementia diagnosis other than AD
Age, Years
also were positively associated with having more ≤ 80 1.00 Reference
than 2 coronal ADJCIs, although these associa- > 80 3.46 0.84-14.21
tions were not statistically significant. On the Children
other hand, having children and having more than No 1.00 Reference
seven years of education were inversely related to Yes 0.19 0.03-1.11

having more than 2 coronal ADJCIs; again, the Education, Years


≤7 1.00 Reference
results were not statistically significant. >7 0.27 0.06-1.16
Root caries. Table 6 presents baseline factors
Housing
associated with the one-year root ADJCIs Own 1.00 Reference
obtained from a backward stepwise (P values Rent 1.02 0.26-4.06
included in the models ≤ .20) logistic regression Nursing home or equivalent 6.64 0.75-59.01

analysis, with root ADJCI as the dichotomized IADL § Score


outcome measure (that is, more than 1 root ADJCI 0-2 1.00 Reference
3-4 2.97 0.71-12.44
versus 0 or 1). As with coronal ADJCIs, the
Dementia Category
strongest predictor of developing more than one
ND¶ 1.00 Reference
new root carious lesion or receiving a restoration AD# 0.64 0.09-4.50
was the number of decayed surfaces at baseline. OD** 4.13 0.44-39.05
Other statistically significant risk factors for * Baseline variables in a multiple logistic regression model were
root ADJCIs were having 20 or more teeth obtained by using a backward stepwise approach.
† Variables excluded from the final model (that is, P > .20) include
(P = .03) and being older than 80 years (P = .01). self-reported health, partial dentures, xerostomia, regular dental
We should point out that having more than seven visits, daily toothbrushing, mobility, sex, marital status, self-rated
disease and Mini-Mental State Examination18 scores.
years of education (P = .02) and a diagnosis of AD ‡ All odds ratios were adjusted for each variable in the table.
(P = .03) were inversely associated with a root § IADL: Instrumental Activities of Daily Living.25
¶ ND: No dementia.
ADJCI of greater than 1. Although not statistically # AD: Alzheimer disease.
significant, self-rated health (good versus fair-poor) ** OD: Other dementia.

was positively associated and a high IADL score


was negatively associated with a root ADJCI of study participants lived in Copenhagen, which
more than 1. has a nonfluoridated water system and a fluoride
level ranging from 0.3 to 0.5 parts per million. All
DISCUSSION participants reported the daily use of regular fluo-
This is the first study, to our knowledge, to com- ridated toothpaste (500-1,500 ppm).
pare the longitudinal caries status of elderly ND group. For participants in the ND group,
people across different dementia diagnoses. All mean MMSE scores were significantly lower and

JADA, Vol. 140 http://jada.ada.org November 2009 1397


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R E S E A R C H

TABLE 6 diction has a number of possible explanations. A


significantly lower mean number of remaining
Baseline factors associated with teeth for the AD group at follow-up could explain
adjusted root caries increments. this finding, because extractions may be perceived
BASELINE FACTOR*† MORE THAN 1 VERSUS 0-1 as an acceptable or even preferred approach to
ROOT CARIES INCREMENT treating substantial dental problems or severe
Odds 95% caries involving several surfaces. In addition, evi-
Ratio ‡ Confidence dence shows great variability in the MMSE scores
Interval
across time for people with AD, and Clark and
No. of Decayed Surfaces
(Coronal and Root)
colleagues27 suggested that measuring cognitive
0 1.00 Reference decline for periods of less than three years is of
1-2 27.35 1.70-441.11 limited value.
3 or more 400.25 12.43-12,884.63
Ptrend ≤ .001 (test of linear trend)
Another possibility is that participants who
received an AD diagnosis were cared for by the
No. of Teeth
1-9 1.00 Reference
hospital system and caregivers, which could
explain, at least in part, why they were less likely

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10-19 2.10 0.40-11.12
20-32 7.31 1.35-39.48 to develop new root surface carious lesions than
Ptrend = .02
were participants in the other two groups. Still
Age, Years
another explanation could be the pharmacological
≤ 80 1.00 Reference
> 80 7.69 1.55-38.15 treatment of AD, which, in many cases, leads to
Education, Years
improvement in cognitive abilities and daily func-
≤7 1.00 Reference tioning.28-30 Also, a side effect of some AD medica-
>7 0.16 0.03-0.74 tions is sialorrhea, which can be protective with
Self-Rated Health regard to caries. We also should note that partici-
Fair-poor 1.00 Reference pants in the baseline AD group who did not par-
Good 3.64 0.78-16.96
ticipate in the follow-up study had a much higher
IADL § Score baseline DS than did participants in the follow-up
0-2 1.00 Reference
3-4 0.35 0.08-1.52 AD group (9.6 versus 6.7).
Dementia Category
OD group. For participants in the OD group,
ND¶ 1.00 Reference the mean number of DSs was significantly higher
AD# 0.08 0.01-0.79 at follow-up than it was at baseline (10.2 versus
OD** 1.01 0.11-9.56
5.0); thus, contrary to our findings in the baseline
* Baseline variables included in a multiple logistic regression model study, people with dementia diagnoses other than
were obtained by using a backward stepwise approach.
† Variables excluded from the final model (that is, P > .20) included AD are at an elevated risk of experiencing declin-
partial denture, xerostomia, regular dental visits, daily tooth- ing oral health after receiving an OD diagnosis.
brushing, mobility, sex, marital status, housing tenure, self-rated
disease, children, Mini-Mental State Examination18 scores. DFS increments. The high DFS increments
‡ All odds ratios were adjusted for each variable in the table. for all three groups indicate a population at an
§ IADL: Instrumental Activities of Daily Living.25
¶ ND: No dementia. elevated risk of developing dental disease.
# AD: Alzheimer disease. Although the differences are not statistically sig-
** OD: Other dementia.
nificant, when we consider the small sample
the number of decayed surfaces was higher at sizes, there is a clinically significant difference
follow-up than at baseline. These findings support between a mean number of coronal ADJCIs of 3.3
the assumption that even people who did not for the ND group, 4.7 for the AD group and 5.8 for
receive a dementia diagnosis at baseline were at the OD group, as well as a clinically significant
risk of experiencing further cognitive decline, difference between a mean number of root ADJCIs
leading to an elevated risk of experiencing deteri- of 3.2 for the ND group, 5.1 for the AD group and
orating oral health. 6.1 for the OD group.
AD group. We found that participants in the The DFS increment (that is, the number of sur-
AD group experienced the smallest difference in faces that developed caries or received a restora-
mean number of DSs between baseline and tion between baseline and follow-up) was not nec-
follow-up despite having a lower mean MMSE essarily consistent with the difference between
score compared with the ND and OD groups, both the numbers of DFSs at baseline and follow-up.
at baseline and follow-up. This apparent contra- The reasons for the discrepancies include surfaces

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Copyright © 2009 American Dental Association. All rights reserved. Reprinted by permission.
R E S E A R C H

changing from filled to carious, which is consid- present or not, but we did not consider whether
ered an increment but does not change the surfaces or teeth were restorable.7
number of DFSs, and surfaces changing from
filled or decayed to missing or unexamined, which CONCLUSION
reduces the number of DFSs but does not affect The primary findings of this study are that
the number of increments. Other factors that elderly people referred to a memory clinic were at
could affect the difference in the number of DFSs an elevated risk of developing high levels of
and increments are reversals (that is, when a sur- coronal and root surface caries during the first
face changes from active caries to inactive caries) year after referral (independent of whether or not
or examiner reversals, which make both the DFS they fulfilled the criteria for a dementia diag-
difference and increments smaller (except for the nosis), and that elderly people with a dementia
CCI, for which the reversals are subtracted from diagnosis other than AD appeared to be at a par-
the increments). ticularly high risk of developing multiple carious
In our analysis, we identified baseline risk lesions during the first year after diagnosis. We
indicators for new root and coronal carious sur- identified a number of baseline characteristics
faces that developed during the follow-up year. that were associated with the development of

Downloaded from jada.ada.org on November 25, 2009


Although our study is among the largest longitu- coronal or root caries during the year after
dinal studies of its kind, our sample size was lim- patients were diagnosed with dementia.
ited, which reduced the study’s power and often These findings raise an important clinical issue
led to wide confidence intervals. In addition, the regarding prevention and geriatric care. Tradi-
criteria we used to select variables for our models tionally, health care providers have paid little
allowed for the inclusion of some variables that attention to patients’ oral health status. The
were not statistically significant at the .05 level. results of our study make a strong case for the
Therefore, our findings should be viewed as gen- active assessment of, and attention to, oral prob-
erating rather than testing a hypothesis. lems in the older, cognitively impaired popula-
Of the variables included in our analysis, the tion. As soon as a patient receives a clinical diag-
strongest baseline predictors of a high (relative to nosis of dementia, he or she should be referred to
low) number of new root or coronal DSs devel- a dentist for effective intervention and adequate
oping during the follow-up period were number of follow-up to prevent further disease progression
teeth and number of decayed (root and coronal) and deterioration of oral health. ■
surfaces, with the greatest risk of developing
Disclosure. None of the authors reported any disclosures.
caries seen among participants with 20 or more
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