CHALLENGES IN STUDIES OF AGEING AND ORAL HEALTH

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2 DEPARTMENT COMMUNITY DENTISTRY AND ORAL PUBLIC HEALTH RESEARCH GROUP GERODONTOLOGY CHALLENGES IN STUDIES OF AGEING AND ORAL HEALTH Prof. Dr. Jacques Vanobbergen, 9 th of June 2017

3 CONTENT Introduction - focus Burden of caries and periodontal disease over lifetime Assess the evidence for age-adequate effective strategies to prevent and treat caries and periodontal disease.

4 CONTENT Introduction - focus Burden of caries and periodontal disease over lifetime Assess the evidence for age-adequate effective strategies to prevent and treat caries and periodontal disease.

5 CONTENT What do we have? What are the methodological challenges? What do we need? Some Discussion interesting section of results of reports recent studies. Published in Looking for the last 10 some years Priorities for evidence? Weaknesses further reserach and limitations of reported studies Searching until saturation

6 INTRODUCTION Focus: Challenges in studies of ageing related to oral public health Parador De La Granja - Spain Joint EFP/ORCA workshop on the bounderies between caries and periodontal diseases. Group 4:.. In the ageing population November 2016

7 INTRODUCTION Focus: Challenges in studies of ageing related to Demographic oral public changes health drive the need to learn more about the burden of oral diseases (in particular Parador De La Granja - Spain caries and periodontal diseases) in older populations. More research is needed to provide the foundation for better prevention and management of these diseases in older populations. Joint EFP/ORCA workshop on the bounderies between caries and periodontal diseases. Tonetti, M. S., Bottenberg P, Conrads G, Eickholz P, Heasman P, Lopez R, Madianos P, Müller F, Needleman I, Nyvad B, Preshaw PM, Pretty I, Renvert S, Group 4:.. In the ageing population Schwendicke F, Trombelli L, vd Putten GJ, Vanobbergen J, West N, Young A, Paris S. Dental caries and periodontal diseases in the ageing population: call to action to protect and enhance oral health and well-being as an essential component of healthy ageing - Consensus report of group 4 of the joint EFP/ORCA workshop on the boundaries be. Journal of Clinical Periodontology 44, S135 S144 (2017).

8 BURDEN OF CARIES AND PERIODONTITIS OVER LIFETIME Introduction - focus Burden of caries and periodontal disease over lifetime Assess the evidence for age-adequate effective strategies to prevent and treat caries and periodontal disease.

9 BURDEN OF CARIES AND PERIODONTITIS OVER LIFETIME Damage due to both periodontitis and caries is largely irreversible and therefore cumulative over the lifetime with age the exposure to risk factors for both periodontitis and caries changes disease experience is certainly increasing with age, but not necessarily due to age Lopez, R., Smith, P. C., Gostemeyer, wendicke, F. (2017) Aging, dental caries and periodontal diseases. Journal of Clinical Periodontology 44:S18, Tonetti, M. S. et al. Dental caries and periodontal diseases in the ageing population: call to action to protect and enhance oral health and well-being as an essential component of healthy ageing - Consensus report of group 4 of the joint EFP/ORCA workshop on the boundaries be. Journal of Clinical Periodontology 44, S135 S144 (2017).

10 BURDEN OF CARIES OVER LIFETIME USA Sheiham, A. et al. BMC Public Health 14, 863 (2014). Petersen, P. E. et al. Community dental health 27, (2010). National Institute for Health and Disability Insurance (NIHDI). PBN: Pilootproject Mondzorg voor Personen met Bijzondere Noden Janssens, B. et al. Community dental health (2017).

11 BURDEN OF CARIES OVER LIFETIME WHO 65+ Americas WHO 65+ Based on 28 teeth Europe Random sample care dependent persons Sheiham, A. et al. BMC Public Health 14, 863 (2014). Petersen, P. E. et al. Community dental health 27, (2010). National Institute for Health and Disability Insurance (NIHDI). PBN: Pilootproject Mondzorg voor Personen met Bijzondere Noden Janssens, B. et al. Community dental health (2017).

12 BURDEN OF CARIES OVER LIFETIME 1275 nursing home residents Belgium Max Sheiham, A. et al. BMC Public Health 14, 863 (2014). Petersen, P. E. et al. Community dental health 27, (2010). National Institute for Health and Disability Insurance (NIHDI). PBN: Pilootproject Mondzorg voor Personen met Bijzondere Noden Janssens, B. et al. Community dental health (2017).

13 BURDEN OF PERIODONTITIS OVER LIFETIME 8.9% (12% EFP) of adults (30-80 years) had severe periodontitis during 2011 to 2012 More prevalent among adults age 50 years Eke, P. I. et al. Journal of Periodontology 1 18 (2015).

14 BURDEN OF PERIODONTITIS OVER LIFETIME Petersen et al. Community dental health 27, (2010).

15 BURDEN OF CARIES AND PERIODONTITIS OVER LIFETIME Introduction - focus Burden of caries and periodontal disease over lifetime Assess the evidence for age-adequate effective strategies to prevent and treat caries and periodontal disease.

16 BURDEN OF CARIES AND PERIODONTITIS OVER LIFETIME Selection bias Low response rates Exclusion of subjects Drop outs Survivor effect Information bias Examiner reliability Validity: Standardisation and comparability Difficulties in doing examination

17 BURDEN OF CARIES AND PERIODONTITIS OVER LIFETIME Selection bias Low response rates (informed consent) Exclusion of subjects Difficulties in obtaining informed consent Exclusion of subjects with cognitive impairment Not sampling institutionalised persons Chalmers, J.M., et al. Caries experience in existing and new nursing home residents in Adelaide, Australia. Gerodontology (2002) 19, Eke, P. I. et al. Journal of Periodontology 1 18 (2015). Heegaard, K.M., Holm-Pedersen, P., Bardow, A., Hvidtfeldt, U.A., Grøbæk, M., and Avlund, K. The Copenhagen Oral Health Senior Cohort: Design, population and dental health. Gerodontology (2015) 28,

18 BURDEN OF CARIES AND PERIODONTITIS OVER LIFETIME Selection bias Drop outs More pronounced in elderly population groups because of worsening health or death. High dropout (70 years >85 years) because of mortality or morbidity 17% to 43% of baseline subjects were deceased at one year follow up. Chalmers, J.M., et al. Caries experience in existing and new nursing home residents in Adelaide, Australia. Gerodontology (2002) 19, Krustrup, U., et al. The overtime effect of social position on dental caries experience in a group of old-aged Danes born in Journal of Public Health Dentistry. (2008) 68, VdPutten GJ, et al. Effectiveness of supervised implementation of an oral health care guideline in care homes: a single-blinded cluster randomised controlled trial. Clin Oral Inv (2013) 17: Hoeksema, A.R., Peters, L.L., Raghoebar, G.M. et al. Oral health status and need for oral care of care-dependent indwelling elderly: from admission to death Clin Oral Invest (2016).

19 BURDEN OF CARIES AND PERIODONTITIS OVER LIFETIME Selection bias Drop outs In most cases there is no information about non-responding care-homes and residents Difficulties in responder-non-responder analyses Replaced by healthier counterparts Hirotomi, T., Kocher, T., Yoshihara, A., Biffar, R., Micheelis, W., Hoffmann, T., Miyazaki, H., and Holtfreter, B. Comparison of periodontal conditions among three elderly populations in Japan and Germany. Journal of Clinical Periodontology (2014) 41, Karki, A.J., Monaghan, N., and Morgan, M. Oral health status of older people living in care homes in Wales. British Dental Journal (2015) 219, Heegaard, K.M., Holm-Pedersen, P., Bardow, A., Hvidtfeldt, U.A., Grøbæk, M., and Avlund, K. The Copenhagen Oral Health Senior Cohort: Design, population and dental health. Gerodontology (2015) 28,

20 Vilstrup, L., Holm-Pedersen, P., Mortensen, E. L., & Avlund, K. Dental status and dental caries in 85-year-old Danes. Gerodontology, (2007) 24(1), Krustrup, U., et al. The overtime effect of social position on dental caries experience in a group of old-aged Danes born in Journal of Public Health Dentistry. (2008) 68, Holmén, A., et al. Oral status in home-dwelling elderly dependent on moderate or substantial supportive care for daily living: Prevalence of edentulous subjects, caries and periodontal disease. Gerodontology )2012). Hirotomi, T., Kocher, T., Yoshihara, A., Biffar, R., Micheelis, W., Hoffmann, T., Miyazaki, H., and Holtfreter, B. Comparison of periodontal conditions among three elderly populations in Japan and Germany. Journal of Clinical Periodontology (2014) 41, Karki, A.J., Monaghan, N., and Morgan, M. Oral health status of older people living in care homes in Wales. British Dental Journal (2015) 219, BURDEN OF CARIES AND PERIODONTITIS OVER LIFETIME Selection bias Survivor effect Premature death because of poor oral health: survivors are the sample Healthy elderly people probably overrepresented in surveys Remaining teeth are survivors without fillings, carious lesions or periodontal disease. Biological elite remains

21 BURDEN OF CARIES AND PERIODONTITIS OVER LIFETIME Information bias Examiner reliability Lack of calibration, sometimes because of frailty of the patients Use of own dentist (trust and more informed consent) Intra-examiner agreement was not recorded due to high age and length of examination Vilstrup, L., Holm-Pedersen, P., Mortensen, E. L., & Avlund, K. Dental status and dental caries in 85-year-old Danes. Gerodontology, (2007) 24(1), Gerritsen, P.F.M., Cune, M.S., Van Der Bilt, A., and De Putter, C. Dental treatment needs in Dutch nursing homes offering integrated dental care. Special Care in Dentistry (2011) 31, Karki, A.J., Monaghan, N., and Morgan, M. Oral health status of older people living in care homes in Wales. British Dental Journal (2015) 219,

22 BURDEN OF CARIES AND PERIODONTITIS OVER LIFETIME Information bias Validity and comparability: Standardisation Validity in one age group does not always mean validity in an other age group Internal validity versus external validity Comparability of indices (CDC/AAP ~ EFP) DMFT not be the best indicator of dental caries among the elderly Use of different periodontal probes. Moreira, R.D.S., Nico, L.S., and Tomita, N.E. Oral health conditions among the elderly in Southeastern São Paulo State. Journal of Applied Oral Science (2009)17, Hirotomi, T., Kocher, T., Yoshihara, A., Biffar, R., Micheelis, W., Hoffmann, T., Miyazaki, H., and Holtfreter, B. Comparison of periodontal conditions among three elderly populations in Japan and Germany. Journal of Clinical Periodontology (2014) 41, Eke, P. I. et al. Journal of Periodontology 1 18 (2015).

23 BURDEN OF CARIES AND PERIODONTITIS OVER LIFETIME Information bias Difficulties in doing examination Examinations were largely done at (nursing) home, risk of underestimation of pathology (caries periodontal disease) position, lighting,.. Large amounts of debris en plaque hindered examination, time spent removing debris diminished the residents cooperative time. Extreme difficulty of examining the frail and medically compromised. resistant behavior Chalmers, J.M., et al. Caries experience in existing and new nursing home residents in Adelaide, Australia. Gerodontology (2002) 19, Peltola P, et al. Oral health and treatment needs of the long-term hospitalised elderly. Gerodontology (2004); 21(2): De Visschere, L.M., Grooten, L., Theuniers, G., and Vanobbergen, J.N. Oral hygiene of elderly people in long-term care institutions - a cross-sectional study. Gerodontology (2006) 23, Vilstrup, L., Holm-Pedersen, P., Mortensen, E. L., & Avlund, K. Dental status and dental caries in 85-year-old Danes. Gerodontology, (2007) 24(1), Holmén, A., et al. Oral status in home-dwelling elderly dependent on moderate or substantial supportive care for daily living: Prevalence of edentulous subjects, caries and periodontal disease. Gerodontology )2012).

24 PREVENTION Also in dentistry!!! Morley, J. E. European Geriatric Medicine 7, (2016).

25 PREVENTION Caries Periodontal disease The underlying evidence for prevention (primary and secondary) and treatment of caries and periodontal disease, irrespective of age but focussing on age-dependent differences in efficacy

26 PREVENTION Introduction - focus Burden of caries and periodontal disease over lifetime Assess the evidence for age-adequate effective strategies to prevent and treat caries and periodontal disease.

27 PREVENTION Periodontal disease Patient-performed control of the biofilm Professional mechanical plaque removal (PMPR) Supportive periodontal treatment (SPT) Chemical control of the dental biofilm Active periodontal treatment (APT) Control/management of risk factors for periodontitis such as smoking and diabetes. Tonetti M, Bottenberg P, Conrads G, Eickholz P, Heasman P, Huysmans MC, Lopez R, Madianos Ph, Müller F, Needleman I, Nyvas B, Preshaw Ph, Pretty I, Renvert S, Schwendicke F, Trombelli L, van der Putten GJ, Vanobbergen J, West N, Young A, Paris S. Dental caries and periodontal disease in the ageing population. J Clin Periodontol 2017;44: S135-S144.

28 PREVENTION Periodontal disease Patient adherence to both effective selfperformed plaque removal (or assisted in the dependent individual) and recall attendance during supportive periodontal therapy are key elements for success. The teeth in the Regular Compliance group had significantly less risk of being lost during SPT than did the teeth in the Erratic Compliance group. (pooled RRTL: 0.56 [CI: 0.38, 0.82], P < 0.01) Lee C, Huang H, Sun T & Karimbux N. Impact of patient compliance on tooth loss during SPT: a systematic review and meta-analysis J Dent Res 2015;4494:

29 PREVENTION Periodontal disease Conclusions: OH - PMPR Needleman I, Nibali L, Di Iorio A. Professional mechanical plaque removal for prevention of periodontal diseases in adults systematic review. J Clin Periodontol 2015;. 42: S12 S35 There is little value in providing PMPR without Oral Hygiene Instructions to reduce gingivitis. Repeated and individually tailored OHI is the key element in achieving gingival health. Strength of recommendation: High, evidence 1. level of PMPR both supra-gingivally and sub-marginally as deep as necessary to remove all soft and hard deposits is required to allow good self-performed oral hygiene. Strength of recommendation: Good Practice point. PMPR as the sole treatment modality is inappropriate in patients with periodontitis. Strength of recommendation: Good Practice point.

30 PREVENTION Introduction - focus Burden of caries and periodontal disease over lifetime Assess the evidence for age-adequate effective strategies to prevent and treat caries and periodontal disease.

31 PREVENTION Selection bias Dropout is always a concern! Exclusion of subjects (frail elderly dementia) Very few studies More inclusive regarding the quality criteria Precision of the estimate (95% CI) Comparability study designs Age groups Lee C, Huang H, Sun T & Karimbux N. Impact of patient compliance on tooth loss during SPT: a systematic review and meta-analysis. J Dent Res 2015;4494: Needleman I, Nibali L, Di Iorio A. Professional mechanical plaque removal for prevention of periodontal diseases in adults systematic review. J Clin Periodontol 2015;. 42: S12 S35

32 PREVENTION Information bias Calibration of the examiners Blinding Examiner blinding Patient blinding Assessment of the compliance Difficulties to include all confounders E.g. motivation of patient / clinician who provides OHI Lee C, Huang H, Sun T & Karimbux N. Impact of patient compliance on tooth loss during SPT: a systematic review and meta-analysis. J Dent Res 2015;4494: Needleman I, Nibali L, Di Iorio A. Professional mechanical plaque removal for prevention of periodontal diseases in adults systematic review. J Clin Periodontol 2015;. 42: S12 S35

33 PREVENTION Periodontal disease Patient-performed control of the biofilm Professional mechanical plaque removal (PMPR) Supportive periodontal treatment (SPT) Chemical control of the dental biofilm Active periodontal treatment (APT) Control/management of risk factors for periodontitis such as smoking and diabetes.

34 PREVENTION Periodontal disease Altogether, the data show that when daily oral hygiene cannot be performed, CHX MW (0,2%) is the first product of choice. A meta-analysis of the effect on de novo plaque formation of CHX DF/gel versus CHX MW resulted in a difference in means of 0.27 [95% CI: 0.14; 0.39] (P < ). Supranoto S, Slot D and Van der Weijden G. The effect of chlorhexidine dentifrice or gel versus chlorhexidine mouthwash on plaque, gingivitis, bleeding and tooth discoloration: a systematic review. Int J Dent Hygiene 13, 2015;

35 PREVENTION CHEMICAL CONTROL OF THE BIOFILM Introduction - focus Burden of caries and periodontal disease over lifetime Assess the evidence for age-adequate effective strategies to prevent and treat caries and periodontal disease.

36 PREVENTION CHEMICAL CONTROL OF THE BIOFILM Selection bias Wide spread of age groups Only three studies could be included Information bias Low to moderate risk of bias Patient blinding not feasible Assessment of compliance? Supranoto S, Slot D and Van der Weijden G. The effect of chlorhexidine dentifrice or gel versus chlorhexidine mouthwash on plaque, gingivitis, bleeding and tooth discoloration: a systematic review. Int J Dent Hygiene 13, 2015;

37 PREVENTION Periodontal disease Patient-performed control of the biofilm Professional mechanical plaque removal (PMPR) Supportive periodontal treatment (SPT) Chemical control of the dental biofilm Active periodontal treatment (APT) Control/management of risk factors for periodontitis such as smoking and diabetes. Tonetti et al. J Clin Periodontol 2017;44: S135-S144.

38 PREVENTION Introduction - focus Burden of caries and periodontal disease over lifetime Assess the evidence for age-adequate effective strategies to prevent and treat caries and periodontal disease.

39 PREVENTION Caries Caries management (continuum of preventive and treatment strategies) Primary prevention: caries onset prevention Rich history of RCT s and Cochrane Reviews involving adolescents and younger children Secondary prevention: arrest of caries lesions Tonetti M, Bottenberg P, Conrads G, Eickholz P, Heasman P, Huysmans MC, Lopez R, Madianos Ph, Müller F, Needleman I, Nyvas B, Preshaw Ph, Pretty I, Renvert S, Schwendicke F, Trombelli L, van der Putten GJ, Vanobbergen J, West N, Young A, Paris S. Dental caries and periodontal disease in the ageing population. J Clin Periodontol 2017;44: S135-S144.

40 PREVENTION Caries Common aetiology for coronal and root caries More vulnerable to demineralisation More efficacious preventive and therapeutic treatments are needed Takahashi & Nyvad Caries Res 2016;50:

41 PREVENTION Caries Caries management (continuum of preventive and treatment strategies) Primary prevention: oral hygiene: daily brushing with FD Fluoride-based therapy Secondary prevention: non-operative approach There is robust evidence suggesting that fluoride-based therapies are efficacious. Evidence from younger patient cohorts in relation to coronal caries is mirrored by evidence examining fluoride use in root caries in older adults Griffin SO, Regnier E, Griffin PM, Huntley V. Effectiveness of fluoride in preventing caries in adults. J Dent Res May;86(5):410-5

42 PREVENTION Caries Caries management (continuum of preventive and treatment strategies) Primary prevention: oral hygiene: daily brushing with FD Fluoride-based therapy Secondary prevention: non-operative approach There is robust evidence suggesting that fluoride-based therapies are efficacious. Evidence from younger patient cohorts in relation to coronal caries is mirrored by evidence examining fluoride use in root caries in older adults Griffin SO, Regnier E, Griffin PM, Huntley V. Effectiveness of fluoride in preventing caries in adults. SR - J Dent Res May;86(5):410-5

43 PREVENTION Caries Fluoride mouthrinse NaF 0,05% (225 ppm)- 0,2%(1000 ppm) (Europe) SnF and Amine F Gibson G, Jurasic M, Wehler C, Jones J, Supplemental fluoride use for moderate and high caries risk adults: a systematic review. J Public Health Dent. 71 (2011)

44 PREVENTION Caries Caries management (continuum of preventive and treatment strategies) Primary prevention: oral hygiene: daily brushing with FD Fluoride-based therapy boosting fluoride concentrations for improved control of root caries in a non-operative approach Secondary prevention: non-operative approach

45 PREVENTION Caries Fluoride varnish 5% NaF (22,600 ppm) Gibson G, Jurasic M, Wehler C, Jones J, Supplemental fluoride use for moderate and high caries risk adults: a systematic review. J Public Health Dent. 71 (2011)

46 PREVENTION Caries Fluoride DF/gel 1,1% NaF paste (5,000 ppm) Gibson G, Jurasic M, Wehler C, Jones J, Supplemental fluoride use for moderate and high caries risk adults: a systematic review. J Public Health Dent. 71 (2011)

47 PREVENTION Caries Fluoride DF/gel 1,1% NaF paste (5,000 ppm) Elderly disabled nursing home residents who had their teeth brushed by the nursing staff twice a day Intervention: 5000 ppm Control: 1450 ppm Ekstrand KR, Poulsen JE, Hede B, Twetman S, Qvist V, Ellwood RP. A randomized clinical trial of the anti-caries efficacy of 5,000 compared to 1,450 ppm fluoridated toothpaste on root caries lesions in elderly disabled nursing home residents. Caries Res. 2013;47(5):391-8

48 PREVENTION Caries Fluoride DF/gel 1,1% NaF paste (5,000 ppm) - risk ratio for not reversing Wierichs, R. J. & Meyer-Lueckel, H. (2015) Systematic review on noninvasive treatment of root caries lesions. Journal of Dental Research 94,

49 PREVENTION Caries Silver Diamine Fluoride (SDF) 28% CHX varnish 1% 3-monthly NaF varnish 5% 3-monthly 38% SDF yearly No intervention was significantly superior to the other Tan HP, Lo EC, Dyson JE, Luo Y, Corbet EF. A randomized trial on root caries prevention in elders. Journal of Dental Research 2010 Oct;89(10): Wierichs, R. J. & Meyer-Lueckel, H. (2015) Systematic review on noninvasive treatment of root caries lesions. Journal of Dental Research 94,

50 PREVENTION Caries Chlorhexidine varnish Conclusion Within the limitations of this review, it may be concluded that in the absence of regular professional tooth cleaning and oral hygiene instructions, CHX-V may provide a beneficial effect for patients in need of special care. The strength of this recommendation is graded as weak. Slot D.E., Vaandrager N.C., Van Loveren C., Van Palenstein Helderman W.H., Van der Weijden G.A. The Effect of Chlorhexidine Varnish on Root Caries: A Systematic Review. Caries Res. 2011;45: Wierichs, R. J. & Meyer-Lueckel, H. (2015) Systematic review on noninvasive treatment of root caries lesions. Journal of Dental Research 94,

51 PREVENTION Caries Conclusion Root caries lesion development can be controlled at the population level by brushing the teeth twice a day with conventional fluoride toothpaste ( ppm F). Active root caries lesions can be converted into inactive lesions by twice daily brushing with conventional fluoride toothpaste ( ppm F), combined with professional applications of 5% NaF varnish or 2% NaF solution 3-4 times a year. Alternatively, lesion arrest might be obtained by brushing lesions twice a day with high-f toothpaste (5000 ppm F). Fluoride interventions should be combined with meticulous dental hygiene and sugar control to optimize the caries-controlling effect. Daily use of a fluoridated mouth-rinse may help in controlling root caries lesion development in the elderly medically compromised patient. Chlorhexidine has no additional effect in combination with regular use of fluoride. Heasman PA, Ritchie M, Asuni A, Gavillet E, Simonsen JL, Nyvad B. Gingival recession and root caries in the ageing population: a critical evaluation of treatments. J Clin Periodontol Mar;44 Suppl 18:S178-S193.

52 PREVENTION Introduction - focus Burden of caries and periodontal disease over lifetime Assess the evidence for age-adequate effective strategies to prevent and treat caries and periodontal disease.

53 PREVENTION Drop out (70 years -> 85 years (mortality/morbidity) Case definition (e.g. activity of RCL) Paucity and poverty of evidence Quantity and quality of studies on fluoride effectiveness among adults! Poor compliance (difficult to control and measure) Patient/examiner blinding is limited Follow-up times rather short Griffin SO, Regnier E, Griffin PM, Huntley V. Effectiveness of fluoride in preventing caries in adults. J Dent Res May;86(5):410-5 Tan HP, Lo EC, Dyson JE, Luo Y, Corbet EF. A randomized trial on root caries prevention in elders. Journal of Dental Research 2010 Oct;89(10): Gibson G, Jurasic M, Wehler C, Jones J, Supplemental fluoride use for moderate and high caries risk adults: a systematic review. J Public Health Dent. 71 (2011) Ekstrand KR, Poulsen JE, Hede B, Twetman S, Qvist V, Ellwood RP. A randomized clinical trial of the anti-caries efficacy of 5,000 compared to 1,450 ppm fluoridated toothpaste on root caries lesions in elderly disabled nursing home residents. Caries Res. 2013;47(5):391-8 Wierichs, R. J. & Meyer-Lueckel, H. (2015) Systematic review on noninvasive treatment of root caries lesions. Journal of Dental Research 94,

54 PREVENTION Drop out (70 years -> 85 years (mortality/morbidity) Case definition (e.g. activity of RCL) Paucity and poverty of evidence Quantity and quality of studies on fluoride effectiveness among adults! Poor compliance Patient/examiner blinding is limited Follow-up times rather short Griffin SO, Regnier E, Griffin PM, Huntley V. Effectiveness of fluoride in preventing caries in adults. J Dent Res May;86(5):410-5 Tan HP, Lo EC, Dyson JE, Luo Y, Corbet EF. A randomized trial on root caries prevention in elders. Journal of Dental Research 2010 Oct;89(10): Gibson G, Jurasic M, Wehler C, Jones J, Supplemental fluoride use for moderate and high caries risk adults: a systematic review. J Public Health Dent. 71 (2011) Ekstrand KR, Poulsen JE, Hede B, Twetman S, Qvist V, Ellwood RP. A randomized clinical trial of the anti-caries efficacy of 5,000 compared to 1,450 ppm fluoridated toothpaste on root caries lesions in elderly disabled nursing home residents. Caries Res. 2013;47(5):391-8 Wierichs, R. J. & Meyer-Lueckel, H. (2015) Systematic review on noninvasive treatment of root caries lesions. Journal of Dental Research 94,

55 RECOMMENDATIONS (RANDOM ORDER) Assessment methods need to be converged, a gold standard for periodontal recording is necessary. Qualitative research methods can be appropriate to understand some complex relationships. Full mobile equipment will be useful. Using the shortest study duration reduces sample bias Griffin SO, Regnier E, Griffin PM, Huntley V. Effectiveness of fluoride in preventing caries in adults. J Dent Res May;86(5):410-5 Ferreira, R.C., De Magalhães, C.S., and Moreira, A.N. Tooth loss, denture wearing and associated factors among an elderly institutionalised Brazilian population. Gerodontology (2008). 25, Eke, P. I. et al. Journal of Periodontology 1 18 (2015). Heegaard, K.M., Holm-Pedersen, P., Bardow, A., Hvidtfeldt, U.A., Grøbæk, M., and Avlund, K. The Copenhagen Oral Health Senior Cohort: Design, population and dental health. Gerodontology (2015) 28,

56 RECOMMENDATIONS (RANDOM ORDER) Previous studies can be useful to improve sampling strategies. Recently evolved, statistically sound alternatives to eliminating cases with missing data are now accepted as state of the art. Full information likelihood procedure Multiple imputation methods Chalmers, J.M., et al. Caries experience in existing and new nursing home residents in Adelaide, Australia. Gerodontology (2002) 19, Palmer RF, Royall DR. Missing data? Plan on it! J Am Geriatric Soc (2010) 58:S343-S348.

57 FUTURE RESEARCH There is an urgent need for epidemiological surveillance of caries, periodontal diseases, tooth loss and oral health-related quality of life in older populations. Tonetti, M. S., Bottenberg P, Conrads G, Eickholz P, Heasman P, Lopez R, Madianos P, Müller F, Needleman I, Nyvad B, Preshaw PM, Pretty I, Renvert S, Schwendicke F, Trombelli L, vd Putten GJ, Vanobbergen J, West N, Young A, Paris S. Dental caries and periodontal diseases in the ageing population: call to action to protect and enhance oral health and well-being as an essential component of healthy ageing - Consensus report of group 4 of the joint EFP/ORCA workshop on the boundaries be. Journal of Clinical Periodontology 44, S135 S144 (2017).

58 FUTURE RESEARCH National oral health surveys need to include representative samples of 65- to 74-year-olds and 75+ There is an urgent need for epidemiological year-olds, including the very old (85 years and older) surveillance of caries, periodontal diseases, and frail and/or care dependent elders, and older tooth loss and oral health-related quality of people with multimorbidity and polypharmacy (e.g. by life in older populations. oversampling). Reporting of surveys need to follow standardized formats in order to allow comparisons and data Tonetti, M. S., Bottenberg P, Conrads G, Eickholz P, Heasman P, Lopez R, Madianos P, Müller F, Needleman I, Nyvad B, Preshaw PM, Pretty I, Renvert S, Schwendicke F, Trombelli L, vd Putten GJ, Vanobbergen J, West N, Young A, Paris S. Dental caries and periodontal diseases in the ageing population: call to action to protect and enhance oral health and well-being as an essential component of healthy ageing - Consensus report of group 4 of the joint EFP/ORCA workshop on the boundaries be. Journal of Clinical Periodontology 44, S135 S144 (2017). synthesis.

59 FUTURE RESEARCH Epidemiological evaluations in older populations should include oral hygiene levels, tooth loss, There is an urgent need for epidemiological attachment level, pocket probing depths and surveillance of caries, periodontal diseases, inflammation (bleeding on probing) as well as the tooth loss and oral health-related quality of presence and number of coronal and root caries life in older populations. lesions, their severity and activity. Quality-of-life measures, salivary secretion rates and (medical) risk factors should also be assessed. Tonetti, M. S., Bottenberg P, Conrads G, Eickholz P, Heasman P, Lopez R, Madianos P, Müller F, Needleman I, Nyvad B, Preshaw PM, Pretty I, Renvert S, Schwendicke F, Trombelli L, vd Putten GJ, Vanobbergen J, West N, Young A, Paris S. Dental caries and periodontal diseases in the ageing population: call to action to protect and enhance oral health and well-being as an essential component of healthy ageing - Consensus report of group 4 of the joint EFP/ORCA workshop on the boundaries be. Journal of Clinical Periodontology 44, S135 S144 (2017).

60 FUTURE RESEARCH Priorities should be placed on how preventive and therapeutic regimens may preserve oral health, quality of life and nutrition into older age as comorbidities present unique challenge to the delivery of intrinsically efficacious and effective strategies. Tonetti, M. S., Bottenberg P, Conrads G, Eickholz P, Heasman P, Lopez R, Madianos P, Müller F, Needleman I, Nyvad B, Preshaw PM, Pretty I, Renvert S, Schwendicke F, Trombelli L, vd Putten GJ, Vanobbergen J, West N, Young A, Paris S. Dental caries and periodontal diseases in the ageing population: call to action to protect and enhance oral health and well-being as an essential component of healthy ageing - Consensus report of group 4 of the joint EFP/ORCA workshop on the boundaries be. Journal of Clinical Periodontology 44, S135 S144 (2017).

61 FUTURE RESEARCH To understand disease progression with age, Priorities should be placed on how preventive future long-term longitudinal studies recording and therapeutic regimens may preserve oral the disease extent and severity of both caries health, quality of life and nutrition into older and periodontitis in these age groups, as well as age as comorbidities present unique a comprehensive set of preventive strategies, challenge to the delivery of intrinsically efficacious and effective strategies. are warranted. Tonetti, M. S., Bottenberg P, Conrads G, Eickholz P, Heasman P, Lopez R, Madianos P, Müller F, Needleman I, Nyvad B, Preshaw PM, Pretty I, Renvert S, Schwendicke F, Trombelli L, vd Putten GJ, Vanobbergen J, West N, Young A, Paris S. Dental caries and periodontal diseases in the ageing population: call to action to protect and enhance oral health and well-being as an essential component of healthy ageing - Consensus report of group 4 of the joint EFP/ORCA workshop on the boundaries be. Journal of Clinical Periodontology 44, S135 S144 (2017).

62 ACKNOWLEDGMENT!!! A valuable input from Drs Barbara Janssens Lynn Janssens Ellen Palmers

63 Prof. Dr. Jacques Vanobbergen community dentistry and oral public health E jacques.vanobbergen@ugent.be Ghent Ghent University thank you for your attention