Impact of minimally invasive dentistry on quality of life of older dentate adults

Transcription

1 Impact of minimally invasive dentistry on quality of life of older dentate adults Finbarr Allen, Professor of Prosthodontics and Oral Rehabilitation Cork Dental School and Hospital, Ireland EADPH Scientific Congress, Istanbul, September 2015

2 Context Changing patterns of Oral Health Challenges of maintaining an aging dentition Minimally invasive dentistry Caries and restorations Tooth replacement

3 Changing Trends in Healthcare Shift from Acute to Chronic disease Mortality to Morbidity Increased life expectancy Pressures on health budgets Politics Economics New Technology Source: Petersen and Yamamoto, Community Dentistry & Oral Epidemiology 2005;33:81-92 Changing Demands & Expectations Changing Demographics

4 Rising Partially Dentate population Source: White DA et al Adult dental health survey 2009: common oral conditions and their impact on the population. Br Dent J 2009;213:567-72

5 The heavy metal generation 65+ age group Increased tooth retention Cumulative effects of disease experience and treatment High prevalence of PAL, caries and toothwear

6 Life Experience Hygiene Diet Smoking Stress Repair

7 Medical Issues Polypharmacy/ xerostomia Drug Generic name Condition Beta Blockers Propanolol Hypertension ACE inhibitors Lisinopril Hypertension Diuretics Frusemide Hypertension Chronic heart failure Calcium channel Nifedipine Hypertension Blockers Stable Angina Hypnotics Diazepam Anxiety Antidepressants Amitryptiline Depression Anti-Parkinson Carbidopa Parkinson s disease

8 Bisphosphonates Widely used medication e.g., Osteoporosis, Breast Cancer, Myeloma management Oral or IV routes Potential for osteonecrosis following surgical procedures May influence decision on whether to extract or retain a tooth

9 Medical Issues self care Rheumatoid Arthritis manual dexterity Scleroderma access for oral hygiene procedures

10 Medical Issues - dementia Impact Ability to maintain plaque control Compliance with care Consent? Liaising with care giver Bacterial Pneumonia?

11 How able is your patient? Medically well Active Independent Cognitively well Medically compromised Inactive Dependent Cognitive Impairment

12 Changing Expectations Less acceptance of doctor knows best Patients <65 years expect more ownership of decision making Greater expectations of what can be done Preference for tooth conservation Dentures associated with ageing Denture avoidance??? Appearance a major concern Source: Cronin M, Meaney S, Jepson N, Allen PF. A qualitative study of trends in patient preferences for the management of partial dentition. Gerodontology 2009;26:137-42

13 The Digital Era

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15 Is oral health important? Untreated dental caries is the most prevalent condition worldwide Shifting from children to adults Peaks at 6y, 25y and 70y

16 What causes dissatisfaction? High disease Low disease, but missing teeth?

17 Health Status Measurement Management of toothloss -Need/Demand gap How effective is our treatment? Are we prioritising resources for oral healthcare appropriately? Limitations of objective measures in health status assessment

18 Conceptual Model for Measuring Oral Health Disease impairment Discomfort & pain Disability Physical H cap Functional limitation Psychological Social Source: Locker D. Measuring oral health: A conceptual framework Community Dental Health 1988;5:3-18

19 Oral Health Impact Profile Oral Health Impact Profile 49 item health status measure 7 conceptual domains Response format In the past year have you. Because of problems with your teeth, mouth or dentures? 0 = never, 1 = hardly ever, 2 = occasionally, 3 = fairly often, 4 = very often Source: Slade G. & Spencer J. Development and evaluation of the Oral Health Impact Profile Community Dental Health 1994;11:3-11.

20 QoL Impacts by age and dental status Source: Slade G, Sanders A J DENT RES 2011;90: Copyright by International & American Associations for Dental Research

21 Longitudinal OHRQoL data Is there a different picture? Does progressive toothloss cause a reduction in QoL? 7 year follow-up in Japan Loss of teeth and reduction of occlusal force predicted decline in OHRQoL Source: Enoki K et al. Determinants of change in oral health related quality of life over 7 years among older Japanese. J Oral Rehabil Apr;40(4):252-7

22 Care of Elders Affordability Accessibility Acceptability

23 Is it all about cost? Utilisation of services decreases with age Why? Cost as a barrier to care evidence varies 19% in the UK (Nuttal et al, 2011) 34% in Australia (Harford et al, 2011) 2% of non-attendance among older adults in 11 European countries attributable to cost (Listl, 2014) Compromised oral, general health, and, lower SES increase the odds of non-utilisation being cost related Level of state subsidy not a predictor of utilisation Other reasons for reducing utilisation of care Accessibility Acceptability

24 How many teeth needed? Aesthetics what bothers the patient? Does the patient complain about ability to chew? Stability of an opposing complete denture?

25 Tooth replacement what do patients want? Denture use as a proxy for satisfaction % RPD use to 8 9 to to to Number of Retained Teeth Source: UK Adult Dental Health Survey 1998

26 What would be ideal?.the retention throughout life of a functional, aesthetic, natural dentition of not less than twenty teeth and not requiring a prosthesis Inherent in this is maintenance and understanding what type of care is acceptable to the elderly World Health Organisation, 1982

27 Caries Prevention and Management Minimise Bacteria Acid Diet Maximise Saliva Awareness Fluoride Environment Adapted from Mount and Hulme; Preservation and Restoration of Tooth Structure

28 To restore or not to restore Risk Maintenance Restorative Cycle Function Improved? Increased Risk?

29 Minimally Invasive Dentistry (MID) Add rather than Subtract Minimally Invasive approach Early diagnosis and prevention Remineralization of early lesions Reduction of cariogenic bacteria Chemomechanical techniques Minimum surgical intervention of cavitated lesions Repair rather than replacement of defective restorations Substrate Chemistry of adhesives Techniques for MID

30 Root Caries Restoration Atraumatic Restorative Treatment (ART) Hand instrumentation No Local Anasthetic needed Restore with GIC

31 Repair or Replace? Patient compliance? In the older patient, repair may be a good choice

32 Relevance of Occlusal Contact Tooth unopposed ART approach 2 years post treatment

33 Plaque control make it easier

34 Plaque control make it easier Planning indirect restorations Ability of patient to maintain Technical issues Old teeth are fragile and limited load bearing capacity!

35 Alternative Strategy Functionally oriented treatment planning Shortened Dental Arch (SDA) concept Focus is on providing a functional as opposed to a complete dentition Use adhesive techniques to fill tooth spaces

36 Fibre Reinforced Composite Resin

37 Fibre Reinforced Composite Resin No preparation

38 Fibre Reinforced Composite Resin Case provided by Prof. N Creugers

39 Extended Shortened Dental Arch Posterior Cantilever RBB Design Features Full wrap around of metal Proximal Groove Occlusal support Light ICP contact on pontic, no contact in excursive movement

40 Comparison of SDA and RPD in 65+ yrs patients (G MCKENNA, et al. Comparison of tooth replacement strategies on Oral Health-related Quality of Life in partially dentate older patients: a randomised controlled clinical trial. Journal of Dentistry 2014 Jun;42(6):653-9.) Enrollment Assessed for eligibility (n=183) Randomised (132) Stratified for age and gender Excluded: Not meeting inclusion criteria (27) Declined to participate (24) Allocated to SHORTENED DENTAL ARCH GROUP (n=67) Received allocated treatment (n=66) Allocation Allocated to REMOVABLE PARTIAL DENTURE GROUP (n=65) Received allocated treatment (n=64) Data collected: Baseline 1 month post treatment 6 month post treatment 12 months post treatment Follow-Up Data collected: Baseline 1 month post treatment 6 month post treatment 12 months post treatment Analysed (n=45) Lost to follow-up (n=22) Excluded from analysis (n=0) Analysis Analysed (n=43) Lost to follow-up (n=22) Excluded from analysis (n=0)

41 OHRQoL by Group from baseline to 1yr

42 Treatment effect The Minimally Important Difference (MID) is : the smallest difference in score in the domain of interest which patients perceive as beneficial and which would mandate...a change in the patient s management (Jaeschke et al.,1989) The MID for OHIP-14 is 5 scale points (Locker et al., 2004)

43 Results: Cost Effectiveness Analysis The cost of achieving the MID for the RPD group = $ The cost of achieving the MID for the SDA group = $ Cost effectiveness ratio = 1:2.05 Financial Costs per patient Materials ($) Laboratory Costs ($) Labour Costs ($) SDA Group (n=45) RPD Group (n=43) * <0.001* <0.001* p Total Cost ($) <0.001* *(p<0.05, paired samples t-test) Source: G MCKENNA, F ALLEN, N WOODS, D O MAHONY, C Da MATA, M CRONIN, C NORMAND. Cost effectiveness of tooth replacement strategies for partially dentate elders. Community Dentistry and Oral Epidemiology 2014 Aug;42(4):366-74

44 Clinical Trials of SDA in >65yrs age RBB versus RPD to restore function Equally acceptable in terms of patient satisfaction Higher incidence (p<0.05) of new disease in the RPD group 11 new carious lesions in RBB Group; 51 new carious lesions in RPD group Sources: NJA JEPSON, PF ALLEN, PJ MOYNIHAN, PJ KELLY, JM THOMASON. Patient satisfaction following the restoration of shortened dental arches. International Journal of Prosthodontics 2003;16: ; NJA JEPSON, PJ MOYNIHAN, PJ KELLY, GW WATSON, JM THOMASON. Caries incidence following restoration of shortened lower dental arches in a randomised controlled trial. Brit Dent J 2001;191:140-4.

45 ART Randomised Clinical Trial Patients over the age of 65 years with active caries requiring restoration Randomly allocated to restoration using ART or Conventional Treatment Outcomes 2 year survival Patient satisfaction Cost Effectiveness Study funded by the Health Research Board; Grant number: HRAPOR/2010/154

46 ART Randomised Clinical Trial 2 year survival 6 months 1 year 2 years Restorations status ART CT ART CT ART CT Total assessed Present, in good condition Acceptable marginal defect or wear Restoration partly or completely missing Caries present* Total failures 4/118 2/124 8/127 4/141 14/96 11/121 Cumulative survival proportions 96.6% 98.3% 93.7% 97.4% 85.4% 90.9% Source: C DA MATA, N WOODS, M CRONIN, PF ALLEN Two-year survival of ART restorations in the elderly: a randomised controlled clinical trial. J Dentistry 2015 Apr;43(4):405-11

47 Patient Satisfaction Global Transition Judgement [Acceptability] 35% 30% 29.8% 27.9% 27.9% 25% 20% 23.4% 23.4% 21% 18.6% 23.4% 15% ART CT 10% 5% 4.70% 0% Small deterioration No change Small improvement Moderate improvement Large improvement Source: C DA MATA, N WOODS, M CRONIN, PF ALLEN Subjective Impact Of Minimally Invasive Dentistry In The Oral Health Of Older Patients. Clin Oral Investig Aug 3. [Epub ahead of print]

48 Economic Analysis Restoration costs Capital costs Consumables ART Labour Conventional Total cost Source: C DA MATA, N WOODS, PF ALLEN. Cost effectiveness of ART in elderly patients. Comm Dent Oral Epidemiol 2014 Feb;42(1):79-87.

49 Results Cost-effectiveness ART (dentist) ART (therapist) Average cost per restoration Survival after one year % % 0.14 CT % 0.29 Costeffectiveness ratios Source: C DA MATA, N WOODS, PF ALLEN. Cost effectiveness of ART in elderly patients. Comm Dent Oral Epidemiol 2014 Feb;42(1):79-87.

50 Minimally Invasive Dentistry Acceptable to elderly patients As a treatment strategy From a functional perspective Less Invasive, Less disease More cost effective, more affordable Effectiveness, accessibility? More primary care based research needed

51 Thank You! Acknowledgements: Dr. G. McKenna Dr. C. Da Mata Dr. M. Cronin Dr. N. Woods Dr. D. O Mahony Health Research Board