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Developing a protocol for a preventive oral health exam for elderly people (EDePAM) using E-Delphi methodology

Abstract

The aim of this study was to develop a Preventive Oral Health Exam for Elderly People (EDePAM), using the e-Delphi technique, to diagnose oral health problems in people 65 or older. The e-Delphi technique was used with experts in multiple stages, and in a final workshop, where an agreement on an examination protocol was reached for diagnosing dental caries, oral mucosa lesions, periodontal diseases, and masticatory function disorders. Quantitative analyses of all the rounds of the e-Delphi method were conducted. It was agreed that the International Caries Detection and Assessment System (ICDAS) should be used together with a modified version of the Nyvad criteria to detect and assess caries lesions. It was also agreed that an assessment was needed of the different factors involved in determining caries risk, namely socioeconomic level, access to fluoride, level of dependence/functionality, salivary flow, history of head and neck cancer treatment, use of medications that decrease salivary flow, diet, use of removable dental prostheses, exposure of root surfaces, and caries history. Furthermore, patients would be required to undergo an examination of the oral mucosa, where any existing lesion should be described in terms of its clinical appearance, location, and risk potential. It was also agreed that an assessment of masticatory function should be performed using the Leake index, together with chewing-gum combined with a color scale to categorize masticatory performance. The number of pairs of occluding antagonist teeth was considered as the best predictor of masticatory function. The 2018 classification by the American Academy of Periodontology (AAP) / European Federation of Periodontology (EFP) was accepted as the standard to assess periodontal status, and it was agreed that this assessment should include an evaluation of clinical attachment loss and bleeding on probing. The novel EDePAM was considered as appropriate for conducting a functional assessment of oral health by providing a comprehensive diagnosis of oral diseases.

Dental Caries; Periodontal Diseases; Diagnosis; Aged

Introduction

Oral diseases are a pandemic, and one of the most challenging public health issues worldwide.11. Beaglehole R, Benzian H, Crail J, Mackay J. The oral health atlas: mapping a neglected global health issue. Brighton: FDI World Dental Education; 2009. The number of people affected by oral diseases increases as the population gets older,22. Kassebaum NJ, Smith AG, Bernabé E, Fleming TD, Reynolds AE, Vos T, et al. Global, regional, and national prevalence, incidence, and disability-adjusted life years for oral conditions for 195 Countries, 1990-2015: a systematic analysis for the global burden of diseases, injuries, and risk factors. J Dent Res. 2017 Apr;96(4):380-7. https://doi.org/10.1177/0022034517693566
https://doi.org/10.1177/0022034517693566...
with a higher prevalence in the most vulnerable groups, thus engendering a significant source of social inequality.33. Jin LJ, Armitage GC, Klinge B, Lang NP, Tonetti M, Williams RC. Global oral health inequalities: task group: periodontal disease. Adv Dent Res. 2011 May;23(2):221-6. https://doi.org/10.1177/0022034511402080
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Poor oral health affects the ability to eat properly, and diminishes self-esteem and quality of life.44. Petersen PE. The World Oral Health Report 2003: continuous improvement of oral health in the 21st century: the approach of the WHO Global Oral Health Programme. Community Dent Oral Epidemiol. 2003 Dec;31(1 Suppl 1):3-23. https://doi.org/10.1046/j..2003.com122.x
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,55. Glick M, Silva OM, Seeberger GK, Xu T, Pucca G, Williams DM, et al. FDI Vision 2020: shaping the future of oral health. Int Dent J. 2012 Dec;62(6):278-91. https://doi.org/10.1111/idj.12009
https://doi.org/10.1111/idj.12009...

Today’s global population is aging rapidly. In Chile, the elderly population increased from 6.6% in 1992 to 11.4% in 2017.66. Instituto Nacional de Estadística de Chile. Síntesis de resultados. Censo. Bogotá: Instituto Nacional de Estadística de Chile; 2017. It is predicted that a demographic crossing will take place by 2025, where the population aged older than 60 will outnumber the population aged younger than 1566. Instituto Nacional de Estadística de Chile. Síntesis de resultados. Censo. Bogotá: Instituto Nacional de Estadística de Chile; 2017.. One of the tools recommended by the World Health Organization (WHO) to evaluate the health of older adults is a functional ability assessment.77. World Health Organization. The world health report 1999: making a difference. Geneve: World Health Organization; 1999. Therefore, one of the goals of public policies for this population should be to increase the number of disability-free years of life.88. Fernández A. II World Assembly on Ageing. Rev Esp Geriatr Gerontol. 2002;37 S2:1-2.

The elderly population in Chile has access to the Elderly Preventive Medicine Exam (EMPAM), a periodic examination for monitoring and evaluating health and functionality.99. Ministerio de Salud (CH). Orientación técnica para la atención de salud de las personas adultas mayores en atención primaria. 2013 [cited 2021 Feb 2]. Available from: http://www.repositoriodigital.minsal.cl/handle/2015/440
http://www.repositoriodigital.minsal.cl/...
However, this exam does not include an evaluation of oral health or oral functionality. When an oral diagnosis tool for elderly people is lacking, consensual methods can provide a way to synthesize information, by determining to what extent the experts in the field agree on a given situation.1010. Jones J, Hunter D. Consensus methods for medical and health services research. BMJ. 1995 Aug;311(7001):376-80. https://doi.org/10.1136/bmj.311.7001.376
https://doi.org/10.1136/bmj.311.7001.376...
One of the most commonly used consensual methods in health is the Delphi technique.1111. Hsu C, Sandford Ba. The Delphi technique: making sense of consensus. Pract Assess, Res Eval. 2007;12:1-8. Generally, this method entails a group of experts responding to a questionnaire, and then receiving feedback based on the collective responses.1111. Hsu C, Sandford Ba. The Delphi technique: making sense of consensus. Pract Assess, Res Eval. 2007;12:1-8. Thus, within a Delphi study, the results of earlier iterations regarding specific statements and/or items can change or be modified by individual panel members in later iterations based on their ability to review and assess the comments and feedback provided by the other Delphi panelists.1111. Hsu C, Sandford Ba. The Delphi technique: making sense of consensus. Pract Assess, Res Eval. 2007;12:1-8. One of the primary characteristics and advantages of the Delphi process is subject anonymity, which can reduce the effects of dominant individuals, often a concern when using group-based processes to collect and synthesize information.

In Chile, there is no examination protocol to diagnose the oral health of elderly people; therefore, the aim of this study was to create a Preventive Oral Health Exam for Elderly People (EDePAM), to be applied in the public health system, based on an electronic Delphi survey (e-Delphi), to enable the diagnosis of oral health problems using a single protocol. This proposal is the response to a call for action that recommends prioritizing research on how to preserve oral health, quality of life, and nutrition in older adults.1212. Tonetti MS, Bottenberg P, Conrads G, Eickholz P, Heasman P, Huysmans MC, 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 between caries and periodontal diseases. J Clin Periodontol. 2017 Mar;44 Suppl 18:S135-44. https://doi.org/10.1111/jcpe.12681
https://doi.org/10.1111/jcpe.12681...

Methodology

Study design

The Delphi method, a method based on expert opinion to achieve a consensus, was used in this study.1313. Young S, Jamieson L. Delivery methodology of the Delphi: a comparison of two approaches. J Park Recreat Admi. 2001 Jan;19:42-58. The Local Research Ethics Committee of the Western Metropolitan Health Service approved this methodological study that has a quantitative approach (Decision number 60: Code 41 / 12.21.2018). The protocol construction process was organized in three phases: a) determining the diseases to be included in the EDePAM, and forming an advisory group, b) conducting an e-Delphi survey, and c) holding a consensus workshop (Figure 1).

Figure 1
Flow chart of the experimental design

Determining the diseases to be included in the EDePAM

The following steps were taken to determine the diseases to be included in the EDePAM: a) a review of the epidemiological studies conducted in Chile to establish the most prevalent, severe and widespread oral conditions in the country, b) an analysis of the national health surveys performed in Chile, c) a review of the scientific literature to establish the most prevalent oral diseases in the elderly population worldwide. A narrative review search was conducted for all the publications related to epidemiologic studies conducted in Chile, whose “Aims” or “Methodology” sections included data on the prevalence of oral diseases among the Chilean elderly. The search was carried out in the Medline (Pubmed), Embase, Cochrane Collaboration and SciELO databases. The inclusion criteria were cross-sectional and longitudinal studies published from 2000 onwards. The exclusion criteria were conference publications, animal and in vitro studies, questionnaire adaptations, and self-reported questionnaires. The search terms were chosen among the Medical Subject Headings of the U. S. National Library of Medicine (NIH-MeSh), namely “Prevalence Study,” “Longitudinal Study,” and also “Local and National Chilean Study.” In addition, international scientific publications related to the global burden of oral diseases from 1990 to 2015 were included in the search, in order to collect data from the conditions of interest in the world population. The results of the National Survey of general health, commissioned by the Ministry of Health for the 2016-2017 period, were retrieved from the corresponding database published on the website of the Ministry of Health, and reviewed for the study.

Advisory group

Prior to starting the e-Delphi survey, an advisory group was created (including authors AM, CC, IE, GM, FC, ADF, and JG), which held several meetings designed to: a) define the appropriate context, b) develop the questionnaire, c) select a list of experts, d) explain the method and objectives to all of the selected experts, and request their collaboration.

e-Delphi survey

Selection of experts

Only national experts were included in the study. Each level had a representation of experts with four possible profiles: dental practitioners in the public or private sector, faculty members of dental schools, and members of scientific societies. These profiles were defined according to several factors, such as number of scientific publications in the area, peer recognition at the national and international levels, positions of responsibility in the government of the country, decision-making capacity within public health services, and positions in scientific societies, among others. Overall, 51 Chilean experts were invited to participate, 14 specializing in dental caries, 11 in lesions of the oral mucosa, 9 in masticatory function, and 17 in periodontal diseases.

This was a convenience sample, with experts representing all sectors of the country, most of which also conducted research in their area of expertise, who spoke Spanish, and who were aware of the current status of existing public policies for the elderly in Chile. Maintaining a balance between the players from state institutions, public and private healthcare providers, members and/or directors of societies of related specialties, as well as those of educational institutions, is essential to maintain a balance between academia and public policy makers and policy implementers in each area. The minimum number of experts per study area included in the Delphi survey was 7, and the final number depended on the availability of experts in each study area.1414. Valdés MG, Marín MS. Delphi method for the expert consultation in the scientific research. Rev Cuba Salud Pública. 2013;39(2):253-67.

The experts were formally invited to participate by means of a letter sent by email, and the Google Forms platform was used to collect and record the participants’ responses to the questionnaires. The average time required to complete each questionnaire was 30 minutes. The whole process was carried out between August 30 and October 23 for cariology, between August 27 and October 15 for masticatory function, between September 6 and November 11 for oral mucosa lesions, and between August 12 and September 12 for periodontal diseases, all during the year of 2019. The system designed allowed keeping the responses private, and the participants, anonymous.

e-Delphi questionnaires

The 1st round consisted of a questionnaire with open-ended questions developed by the advisory group, based on the previously proposed and developed objectives. The questions of the 2nd round were formulated based on the responses provided by the experts in the 1st round. The questions had the following objectives, according to the area of study:

  1. dental caries: to reach an agreement on the methods of detection/classification of caries lesions, and on a risk assessment method for elderly people (1st round: 4 questions; 2nd round: 7 questions) (Table);

    Table
    Question and answers from the 1st round.

  2. lesions of the oral mucosa: to reach an agreement on an examination method for the oral mucosa, including recommended tools, examination time, and a proposed method for recording oral mucosal lesions (1st round: 10 questions, 2nd round: 6 questions) (Table);

  3. masticatory function: to determine the materials and methods to assess masticatory performance, to define a questionnaire to assess chewing ability, and to determine the variables or clinical characteristics with the highest predictive value to assess masticatory function (1st round: 4 questions, 2nd round: 4 questions) (Table);

  4. periodontal diseases (two complementary objectives): to assess the feasibility of implementing the American Academy of Periodontology (AAP) / European Federation of Periodontology (EFP) 2018 classification during periodontal examination, and to collect the opinion of experts on the possibility of implementing this new classification by general practitioners (1st round: 8 questions; 2nd round: 10 questions) (Table).

A 3rd round was required only for the dental caries group (1 question) and the masticatory function group (5 questions), because of the lack of consensus on some of the questions. A consensus was achieved only when agreement was higher than 60%. In the 2nd and 3rd rounds, most of the questions had closed-ended answers to be selected by the participants (example: “totally disagree,” “disagree,” “neither agree nor disagree,” “agree,” “totally agree”) or were dichotomous (“Yes/No”).

Consensus workshop

After the results of the e-Delphi survey were obtained, a consensus workshop was held (November 2019). Twenty-six professionals took part in the consensus workshop, including eight experts who participated in the previous stages, as well as professionals in charge of dental programs in health centers, professional specialists, and general dentists working in both the public health system and private dental practices in different Chilean cities. The objectives of the consensus workshop were: a) to review and analyze the results obtained, b) to broaden the discussion on the topics requiring further explanation, and c) to carry out a final discussion and analysis of the conclusions. A flow chart of the study design is presented in Figure 1.

Data analysis

Quantitative analyses were conducted of all the rounds of the e-Delphi survey. In the 1st round, the responses were grouped according to common categories, and summarized in the form of percentages. For all of the questions, a consensus was considered as “reached” when more than 60% of the experts selected the same response. In the case of questions with different levels of agreement, a consensus was considered as “reached” when more than 60% of the experts selected the “agree” or “totally agree” options. The related literature reports agreement rates between 51% and 80% among experts as representing a consensus.1515. Diamond IR, Grant RC, Feldman BM, Pencharz PB, Ling SC, Moore AM, et al. Defining consensus: a systematic review recommends methodologic criteria for reporting of Delphi studies. J Clin Epidemiol. 2014 Apr;67(4):401-9. https://doi.org/10.1016/j.jclinepi.2013.12.002
https://doi.org/10.1016/j.jclinepi.2013....
,1616. Hung HL, Altschuld JW, Lee YF. Methodological and conceptual issues confronting a cross-country Delphi study of educational program evaluation. Eval Program Plann. 2008 May;31(2):191-8. https://doi.org/10.1016/j.evalprogplan.2008.02.005
https://doi.org/10.1016/j.evalprogplan.2...

Results

Determining the diseases to be included in the EDePAM:

The results showed that the most prevalent diseases and conditions for elderly people were dental caries, periodontitis, lesions of oral mucosa, and reduced masticatory function.1717. Espinoza I, Rojas R, Aranda W, Gamonal J. Prevalence of oral mucosal lesions in elderly people in Santiago, Chile. J Oral Pathol Med. 2003 Nov;32(10):571-5. https://doi.org/10.1034/j.1600-0714.2003.00031.x
https://doi.org/10.1034/j.1600-0714.2003...

18. Urzua I, Mendoza C, Arteaga O, Rodríguez G, Cabello R, Faleiros S, et al. Dental caries prevalence and tooth loss in chilean adult population: first national dental examination survey. Int J Dent. 2012;2012:810170. https://doi.org/10.1155/2012/810170
https://doi.org/10.1155/2012/810170...

19. Strauss FJ, Espinoza I, Stähli A, Baeza M, Cortés R, Morales A, et al. Dental caries is associated with severe periodontitis in Chilean adults: a cross-sectional study. BMC Oral Health. 2019 Dec;19(1):278. https://doi.org/10.1186/s12903-019-0975-2
https://doi.org/10.1186/s12903-019-0975-...

20. Gamonal J, Mendoza C, Espinoza I, Muñoz A, Urzúa I, Aranda W, et al. Clinical attachment loss in Chilean adult population: First Chilean National Dental Examination Survey. J Periodontol. 2010 Oct;81(10):1403-10. https://doi.org/10.1902/jop.2010.100148
https://doi.org/10.1902/jop.2010.100148...

21. Prince MJ, Wu F, Guo Y, Gutierrez Robledo LM, O’Donnell M, Sullivan R, et al. The burden of disease in older people and implications for health policy and practice. Lancet. 2015 Feb;385(9967):549-62. https://doi.org/10.1016/S0140-6736(14)61347-7
https://doi.org/10.1016/S0140-6736(14)61...
-2222. Morales A, Jara G, Werlinger F, Cabello R, Espinoza I, Giacaman R, et al. Sinopsis de la situación de salud oral en Chile - Parte II: diagnósticos poblacionales de salud oral. Int J Interdiscip Dent. 2020 Aug;13(2):88-94. https://doi.org/10.4067/S2452-55882020000200088
https://doi.org/10.4067/S2452-5588202000...

e-Delphi survey

Experts/professionals

The response/participation rate was 88.2% (45 of 51 experts). The panels were composed of 11/14 experts in the area of dental caries, 11/11 in lesions of the oral mucosa, 8/9 in masticatory function, and 15/17 in periodontal diseases. The 45 professionals were distributed as follows: 24 were university professors, 12 belonged to the public sector, 1 to the private sector, and 8 to different scientific societies.

e-Delphi Questionnaires

a.Dental caries: It was agreed that the International Caries Detection and Assessment System (ICDAS) was appropriate for the detection/classification of coronal and root caries lesions, and that the Nyvad criteria were appropriate for the classification of caries lesion activity in older adults. Furthermore, it was agreed that the most relevant factors for the assessment of caries risk in older adults were access to fluoride, use of salivary flow–decreasing medications, diet, root surface exposure, salivary flow, level of dependence/functionality, history of head and neck cancer treatment, socioeconomic level, use of removable dental prosthesis, and past caries experience (Table, Figure 2, and Figure 3).

Figure 2
Questions and answers of the e-Delphi survey for dental caries, 2nd round

Figure 3
Factors to be considered in the assessment of caries risk among older people, e-Delphi survey for dental caries, 3rd round

b.Lesions of the oral mucosa: it was agreed that all the patients should undergo an oral mucosa examination, consisting of inspection and palpation from the outside to the inside of the oral cavity, using a basic examination tool (mirror), gauze and tongue depressor, taking 3-5 minutes, and describing each lesion clinically by reporting its type, location, and malignancy potential. Any suspected oral cancer, pemphigus, oral pemphigoid or candidiasis should prompt a high priority referral to a specialist in oral pathology (Table). In addition, there was agreement on the importance of making a photographic record of any lesion and using the topographical register proposed by the WHO and modified by Roed-Petersen (WHO 1980) to record oral mucosal lesions. The essential lesions to be considered were ulcer, plaque, and node, followed by vesicular lesion, tumor, macula and papule.

c.Masticatory function: there was a consensus among the experts that the Leake index should be used to assess chewing ability (Table, Figure 4, Figure 5). In the 3rd round, a color-changeable chewing gum (Masticatory Performance Evaluating Gum XYLITOL®, Lotte, Tokyo, Japan) and associated color scale reached the highest level of agreement to assess masticatory performance, according to the criteria of technical, operational, economic, and clinical time feasibility (Figure 6). The number of pairs of occluding antagonist teeth was considered the clinical variable with the highest predictive value for masticatory function.

Figure 4
Materials and methods used to assess masticatory performance, e-Delphi survey for chewing functionality, 2nd round

Figure 5
Questionnaires and variables used to assess chewing functionality, e-Delphi survey for chewing functionality, 2nd round

Figure 6
Masticatory performance tests to be implemented as a public health policy, according to different levels of feasibility, e-Delphi survey for chewing functionality, 3rd round

d.Periodontal diseases: expert consensus was reached on the following points: the imperative adoption of the AAP/EFP 2018 classification system, the need to perform a full-mouth periodontal examination to reach a diagnosis, the use of the North Carolina periodontal probe as a standardized tool to measure periodontal clinical parameters, the recognition of clinical attachment loss (CAL) as the appropriate clinical parameter to diagnose periodontitis, and the selection of bleeding on probing (BOP) as the appropriate clinical parameter to diagnose gingivitis, the need to record periodontal parameters in a periodontal chart, and the need to perform a full-mouth radiographic examination to establish the different stages and grades of periodontitis (Table). The experts also agreed that the mean duration of a periodontal examination should be 30 minutes (Figure 7), and commented on the need for providing specific training to general practitioners to ensure successful implementation of the AAP/EFP 2018 classification system.

Figure 7
Questions and answers of the e-Delphi survey for periodontology, 2nd round

Consensus workshop

A total of 26 professionals participated in the Consensus Workshop, including eight experts who participated in the previous stages, and 18 new professionals who were in charge of dental programs in health centers, professional specialists, and general dentists working in the public health system or in private dental practices in different Chilean cities.

A consensus was reached on the need to categorize the caries risk assessed by the EDePAM in older adults, in order to address this risk using appropriate therapies. A tool was developed for the assessment of caries risk based on the factors agreed upon by the experts, on the available scientific evidence, and on the feasibility of using it in clinical practice. It was also agreed that 4 levels of risk should be considered during the oral mucosa examination, to determine the priority of referring the patient to an oral and maxillofacial pathology specialist, or to a professional from another medical/dental specialty, as follows:

  1. High risk: suspicion of oral cancer, potentially malignant disorders or autoimmune lesions in the oral mucosa;

  2. Moderate risk: benign neoplasm, chronic traumatic or infectious injuries, among others;

  3. Low risk: other changes or vascular malformations.

A consensus was reached on the need to categorize masticatory function, and to provide guidance for the rehabilitation treatment. It was agreed that a questionnaire should be included assessing the presence of temporomandibular disorders or orofacial pain, and that this would be useful to determine the need for referral to secondary care by a specialist. The questionnaire included a TMD-pain screener, validated in Spanish, which is part of a DC/TMD protocol2323. Gonzalez Y, Castrillón E, Oyarzo J, Espinoza de Santillana I, Ortiz F, Velasco Neri J, et al. Diagnostic criteria for temporomandibular disorders: assessment. criterios diagnósticos para trastornos temporomandibulares: instrumentos de evaluación: español instruments. Versión 2016 May 26 [cited 2020 Apr 6]. Available from: www.rdc-tmdinternational.org
www.rdc-tmdinternational.org...
. Finally, it was suggested that an assessment of prosthetic function be included, consisting of an evaluation of prosthesis support, retention, stability, aesthetics, occlusion and usage time. It was also agreed that several parameters should be considered in the examination of patients rehabilitated with removable prostheses, and that these should be categorized as adequate or inadequate, according to clearly defined criteria. The parameters were: a) Type of prosthesis; b) Material of manufacture and its condition; c) Aesthetic control, including gingival dental contour, color and size; d) Prosthesis integrity and limits, including posterior extension of the maxillary prosthesis, posterior extension of the mandibular prosthesis, buccal flange of the maxillary and mandibular prostheses, lingual limit, and relief areas; e) Retention and occlusion complex, including retention complex, i.e. Integrity-retention-passive-support-stabilization, and occlusion, recorded in maximum intercuspation (MIC) and during excursive movements; f) Response to functional forces, including support, retention, and stability. Should any of these parameters be assessed as inadequate, the possibility of addressing them satisfactorily should be evaluated, and should this prove not possible, a new prothesis should be made.

Finally, any repair made to the prosthesis should be noted and assessed as adequate or inadequate, according to the parameters described above, hence allowing a decision to be made on whether further repair is possible, or whether a new prosthesis should be made. In addition, it was agreed that a peri-implant assessment should be included as part of the periodontal diagnosis, following the criteria of the new classification of periodontal and peri-implant diseases. The complete Protocol for the Preventive Oral Health Exam for Elderly People is presented in Figure 8.

Figure 8
Protocol of the Preventive Oral Health Exam for Elderly People

Discussion

This study, using e-Delphi methodology, resulted in the creation of the Preventive Oral Health Exam for Elderly People (EDePAM). As described above, the elderly population in Chile has access to a periodic examination for monitoring and evaluating their general health and functionality (EMPAM); however, this exam does not include an evaluation of their oral health and functionality. The rationale underlying our proposal, aimed at strengthening public policies for the elderly, was that the EDePAM could be used to complement the EMPAM, by providing an assessment of the oral functionality of the elderly assisted at the primary health level. To the best of our knowledge, there is no such exam elsewhere in the world capable of providing this assessment of oral functionality among the elderly, through a Preventive Oral Health Exam for Elderly People. We believe that this oral dimension should be part of other general health examination protocols carried out worldwide for older adults, and included in a public policy proposal at the international level.

Detecting and assessing caries lesions, as well as ascertaining caries risk, are required to create and implement dental care programs capable of addressing prevention, treatment and follow-up, with a patient-centered approach.1212. Tonetti MS, Bottenberg P, Conrads G, Eickholz P, Heasman P, Huysmans MC, 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 between caries and periodontal diseases. J Clin Periodontol. 2017 Mar;44 Suppl 18:S135-44. https://doi.org/10.1111/jcpe.12681
https://doi.org/10.1111/jcpe.12681...
,2424. Martignon S, Pitts NB, Goffin G, Mazevet M, Douglas GV, Newton JT, et al. CariesCare practice guide: consensus on evidence into practice. Br Dent J. 2019 Sep;227(5):353-62. https://doi.org/10.1038/s41415-019-0678-8
https://doi.org/10.1038/s41415-019-0678-...
The present study agreed on the use of ICDAS criteria for coronal and root caries lesions. ICDAS allows classifying caries lesions from a very early stage up to an advanced caries process, with extensive cavitation.2525. Ismail AI, Sohn W, Tellez M, Amaya A, Sen A, Hasson H, et al. The International Caries Detection and Assessment System (ICDAS): an integrated system for measuring dental caries. Community Dent Oral Epidemiol. 2007 Jun;35(3):170-8. https://doi.org/10.1111/j.1600-0528.2007.00347.x
https://doi.org/10.1111/j.1600-0528.2007...
However, it fails to provide criteria for the entire caries lesion process, which includes more advanced stages, from pulpally involved teeth to caries-associated tooth loss, as do other systems, such as the Caries Assessment Spectrum and Treatment (CAST) or PUFA.2626. Monse B, Heinrich-Weltzien R, Benzian H, Holmgren C, van Palenstein Helderman W. PUFA: an index of clinical consequences of untreated dental caries. Community Dent Oral Epidemiol. 2010 Feb;38(1):77-82. https://doi.org/10.1111/j.1600-0528.2009.00514.x
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,2727. Leal SC, Ribeiro AP, Frencken JE. Caries Assessment Spectrum and Treatment (CAST): a novel epidemiological instrument. Caries Res. 2017;51(5):500-6. https://doi.org/10.1159/000479042
https://doi.org/10.1159/000479042...
These detection and assessment systems also fail to support an assessment for caries lesion activity. For that reason, it was agreed that lesion detection was to be supplemented by using the Nyvad’s criteria to assess lesion activity.2828. Nyvad B, Baelum V. Nyvad criteria for caries lesion activity and severity assessment: a validated approach for clinical management and research. Caries Res. 2018;52(5):397-405. https://doi.org/10.1159/000480522
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There is limited evidence on how well existing models can assess caries risk to the extent of predicting the occurrence of new lesions.2929. Cagetti MG, Bontà G, Cocco F, Lingstrom P, Strohmenger L, Campus G. Are standardized caries risk assessment models effective in assessing actual caries status and future caries increment? A systematic review. BMC Oral Health. 2018 Jul;18(1):123. https://doi.org/10.1186/s12903-018-0585-4
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,3030. Tellez M, Gomez J, Pretty I, Ellwood R, Ismail AI. Evidence on existing caries risk assessment systems: are they predictive of future caries? Community Dent Oral Epidemiol. 2013 Feb;41(1):67-78. https://doi.org/10.1111/cdoe.12003
https://doi.org/10.1111/cdoe.12003...
No agreement among the experts was reached in this e-Delphi survey regarding the use of a pre-existing tool; rather, it was agreed that an assessment of specific risk and protective factors should be conducted separately. Furthermore, access to fluoride, use of salivary flow–decreasing medications, diet, exposed root surfaces, salivary flow, level of functionality, history of head and neck cancer treatment, socioeconomic level, use of removable dental prostheses, and past caries experience were considered the most relevant factors for assessing caries risk in this age group. Therefore, based on this consensus, it was decided that a caries risk assessment tool should be created to be used in association with the EDePAM.

There was a significant agreement in the expert group on the need to perform an examination of the oral mucosa of the elderly, and on the importance of a systematic process whereby clinical appearance, location (based on the WHO topographical register), specific diagnoses, and anatomical references can be recorded. Studies in Chile have ascertained that the prevalence of one or more lesions of the oral mucosa is high among older adults, ranging between 53%1717. Espinoza I, Rojas R, Aranda W, Gamonal J. Prevalence of oral mucosal lesions in elderly people in Santiago, Chile. J Oral Pathol Med. 2003 Nov;32(10):571-5. https://doi.org/10.1034/j.1600-0714.2003.00031.x
https://doi.org/10.1034/j.1600-0714.2003...
and 67.5%.3131. Cueto A, Martínez R, Niklander S, Deichler J, Barraza A, Esguep A. Prevalence of oral mucosal lesions in an elderly population in the city of Valparaiso, Chile. Gerodontology. 2013 Sep;30(3):201-6. https://doi.org/10.1111/j.1741-2358.2012.00663.x
https://doi.org/10.1111/j.1741-2358.2012...
The most frequent oral mucosa lesions are traumatic lesions,3232. Rivera C, Droguett D, Arenas-Márquez MJ. Oral mucosal lesions in a Chilean elderly population: a retrospective study with a systematic review from thirteen countries. J Clin Exp Dent. 2017 Feb;9(2):e276-83. https://doi.org/10.4317/jced.53427
https://doi.org/10.4317/jced.53427...
but oral cancer and manifestations of systematic diseases may also be diagnosed. One concern of the panel was the need for referring patients to specialists, and for providing a classification of risk levels, later recommended. Potentially malignant disorders and oral cancer were among the oral mucosa lesions highlighted. This is in agreement with the evidence that shows that older adults have the highest incidence of oral cancer and associated mortality rates in Chile,3333. Riera P, Martínez B. Morbilidad y mortalidad por cáncer oral y faríngeo en Chile. Rev Med Chil. 2005 May;133(5):555-63. https://doi.org/10.4067/S0034-98872005000500007
https://doi.org/10.4067/S0034-9887200500...
and the worst survival rates.3434. Maraboli-Contreras S, Adorno D, Maturana A, Rojas G. Fuentes- Alburquenque M., Espinoza- Santander I. Sobrevida de carcinoma oral de células escamosas: reporte de la Universidad de Chile. Rev Clín Periodoncia Implantol Rehabil Oral. 2018;11(3):147-51. https://doi.org/10.4067/S0719-01072018000300147
https://doi.org/10.4067/S0719-0107201800...
It is of paramount importance to improve the methods to systematize the examination protocol and the referral to specialists. To this end, the present study offers its contribution by providing straightforward recommendations for implementing these measures in routine oral exams.

There was a significant agreement in the expert group on the need to implement the AAP/EFP 2018 classification system.3535. Caton JG, Armitage G, Berglundh T, Chapple IL, Jepsen S, Kornman KS, et al. A new classification scheme for periodontal and peri-implant diseases and conditions - Introduction and key changes from the 1999 classification. J Periodontol. 2018 Jun;89 Suppl 1:S1-8. https://doi.org/10.1002/JPER.18-0157
https://doi.org/10.1002/JPER.18-0157...
To be fully implemented, this classification system requires the use of a standardized measuring tool (North Carolina periodontal probe), full mouth periodontal examination recorded in an ad hoc periodontal chart, and full mouth x-ray examination. The expert panel considered the use of the CAL and BOP indexes as essential for establishing the diagnoses of periodontitis and gingivitis, respectively. The classification system is straightforward in its application, but requires special training to be correctly implemented. The expert panel agreed that general practitioners would require some formal training to use the classification system in their routine practice.

The average amount of time required for applying the EDePAM was estimated to be 60 minutes, considering a completely dentate older person. The first 15 minutes are to be used by a dental hygienist, and the other 45 minutes, by a dentist. However, it was estimated that the time would be considerably lower for edentulous and for partially dentate older adults, which are prevalent in Chile (where there is an average of 20.6 missing teeth among the population in this age range2020. Gamonal J, Mendoza C, Espinoza I, Muñoz A, Urzúa I, Aranda W, et al. Clinical attachment loss in Chilean adult population: First Chilean National Dental Examination Survey. J Periodontol. 2010 Oct;81(10):1403-10. https://doi.org/10.1902/jop.2010.100148
https://doi.org/10.1902/jop.2010.100148...
).

The elderly population has poor oral health, and this is related to the process of becoming frail.3636. Andrade FB, Lebrão ML, Santos JL, Duarte YA. Relationship between oral health and frailty in community-dwelling elderly individuals in Brazil. J Am Geriatr Soc. 2013 May;61(5):809-14. https://doi.org/10.1111/jgs.12221
https://doi.org/10.1111/jgs.12221...
,3737. Hakeem FF, Bernabé E, Sabbah W. Association between oral health and frailty: a systematic review of longitudinal studies. Gerodontology. 2019 Sep;36(3):205-15. https://doi.org/10.1111/ger.12406
https://doi.org/10.1111/ger.12406...
Therefore, it is essential that objective tools be developed and validated to assess oral function. One of the main oral functions is chewing, a complex process related to digestion, nutrition, and, for the elderly, even to higher functions of the central nervous system, such as learning and memory.3838. Hara T, Kawanishi K, Ohno A, Iida S. The evolution of research on occlusion and brain function. J Prosthodont Res. 2017 Jan;61(1):6-8. https://doi.org/10.1016/j.jpor.2016.06.001
https://doi.org/10.1016/j.jpor.2016.06.0...
Not all the methods used to evaluate masticatory function fulfill the requirements for direct application while providing dental care to elderly people.3939. Manly RS, Braley LC. Masticatory performance and efficiency. J Dent Res. 1950 Aug;29(4):448-62. https://doi.org/10.1177/00220345500290040701
https://doi.org/10.1177/0022034550029004...

40. Nakasima A, Higashi K, Ichinose M. A new, simple and accurate method for evaluating masticatory ability. J Oral Rehabil. 1989 Jul;16(4):373-80. https://doi.org/10.1111/j.1365-2842.1989.tb01353.x
https://doi.org/10.1111/j.1365-2842.1989...

41. Kapur KK, Soman SD. Masticatory performance and efficiency in denture wearers. 1964. J Prosthet Dent. 2006 Jun;95(6):407-11. https://doi.org/10.1016/j.prosdent.2006.03.012
https://doi.org/10.1016/j.prosdent.2006....
-4242. Schimmel M, Christou P, Herrmann F, Müller F. A two-colour chewing gum test for masticatory efficiency: development of different assessment methods. J Oral Rehabil. 2007 Sep;34(9):671-8. https://doi.org/10.1111/j.1365-2842.2007.01773.x
https://doi.org/10.1111/j.1365-2842.2007...
The opinion of the e-Delphi panel of experts coincided with the opinion prevailing in the scientific literature regarding the use of a color-changeable chewing-gum4343. Ishikawa Y, Watanabe I, Hayakawa I, Minakuchi S, Uchida T. Evaluations of masticatory performance of complete denture wearers using color-changeable chewing gum and other evaluating methods. J Med Dent Sci. 2007 Mar;54(1):65-70. associated with a color scale4444. Hama Y, Kanazawa M, Minakuchi S, Uchida T, Sasaki Y. Reliability and validity of a quantitative color scale to evaluate masticatory performance using color-changeable chewing gum. J Med Dent Sci. 2014 Mar;61(1):1-6. as the most appropriate test material and method to assess masticatory performance in the dental clinic, without having to have additional equipment, in a short period of time and at a low cost.4545. Kamiyama M, Kanazawa M, Fujinami Y, Minakuchi S. Validity and reliability of a Self-Implementable method to evaluate masticatory performance: use of color-changeable chewing gum and a color scale. J Prosthodont Res. 2010 Jan;54(1):24-8. https://doi.org/10.1016/j.jpor.2009.08.001
https://doi.org/10.1016/j.jpor.2009.08.0...
,4646. Lin CS, Wu SY, Wu CY, Ko HW. Gray Matter Volume and Resting-State Functional Connectivity of the Motor Cortex-Cerebellum Network Reflect the Individual Variation in Masticatory Performance in Healthy Elderly People. Front Aging Neurosci. 2016 Jan;7:247. https://doi.org/10.3389/fnagi.2015.00247
https://doi.org/10.3389/fnagi.2015.00247...
Self-reports or visual analogue scale questionnaires are currently the most commonly accepted ways to evaluate masticatory ability, and provide a subjective assessment of chewing.4747. Kang SM, Lee SS, Kwon HK, Kim BI. Short-term improvement of masticatory function after implant restoration. J Periodontal Implant Sci. 2015 Dec;45(6):205-9. https://doi.org/10.5051/jpis.2015.45.6.205
https://doi.org/10.5051/jpis.2015.45.6.2...
Among these methods, the Leake index4848. Leake JL. An index of chewing ability. J Public Health Dent. 1990;50(4):262-7. https://doi.org/10.1111/j.1752-7325.1990.tb02133.x
https://doi.org/10.1111/j.1752-7325.1990...
was considered by the experts as simple, fast and easy to use in the clinical environment.4949. Peek CW, Gilbert GH, Duncan RP. Predictors of chewing difficulty onset among dentate adults: 24-month incidence. J Public Health Dent. 2002;62(4):214-21. https://doi.org/10.1111/j.1752-7325.2002.tb03447.x
https://doi.org/10.1111/j.1752-7325.2002...
,5050. Palomares T, Montero J, Rosel EM, Del-Castillo R, Rosales JI. Oral health-related quality of life and masticatory function after conventional prosthetic treatment: a cohort follow-up study. J Prosthet Dent. 2018 May;119(5):755-63. https://doi.org/10.1016/j.prosdent.2017.07.023
https://doi.org/10.1016/j.prosdent.2017....
Finally, the number of pairs of occluding antagonist teeth was chosen as the clinical variable with the highest predictive value of masticatory function, which is related to the incidence of frailty in elderly people.3737. Hakeem FF, Bernabé E, Sabbah W. Association between oral health and frailty: a systematic review of longitudinal studies. Gerodontology. 2019 Sep;36(3):205-15. https://doi.org/10.1111/ger.12406
https://doi.org/10.1111/ger.12406...

An important limitation of this study is that the results obtained only represent the opinions and beliefs of a subgroup of experts in the areas of cariology, oral medicine, physiology, and periodontics. The selection of these experts and their opinions can be considered a source of bias. However, this is something inherent in the e-Delphi methodology, and this bias is expected to be reduced by specific measures provided for in the methodology itself. It should also be noted that about 10% of the experts selected did not respond, or declined to participate. Although an international pool of experts would have been desirable, we chose national experts, since this instrument is intended for use in Chile. After having reached a consensus among the experts, we held a consensus workshop in which only eight experts had previously participated in an e-Delphi consensus. The objective of this session was to present the consensus already reached by the experts to other professionals from different Chilean cities, who could provide us with other perspectives on the proposed exam. Thus, the eight experts were assigned to different work tables where they explained the study findings to professionals in charge of dental programs in health centers, professional specialists, general dentists working in the public health system and in private dental practices.

The strength of this study was the original contribution of a group of experts to creating a unique protocol for an oral health exam for elderly people, thus enabling the development of specific measures of health promotion, prevention, treatment and clinical follow-up to be validated and implemented in a future clinical trial. In the present study, we established a minimum consensus of 60% of the answers given by the experts, and the range of agreement obtained was 60% to 100%. These percentages are within the ranges reported by the scientific literature, namely 51% to 80%.1515. Diamond IR, Grant RC, Feldman BM, Pencharz PB, Ling SC, Moore AM, et al. Defining consensus: a systematic review recommends methodologic criteria for reporting of Delphi studies. J Clin Epidemiol. 2014 Apr;67(4):401-9. https://doi.org/10.1016/j.jclinepi.2013.12.002
https://doi.org/10.1016/j.jclinepi.2013....
,1616. Hung HL, Altschuld JW, Lee YF. Methodological and conceptual issues confronting a cross-country Delphi study of educational program evaluation. Eval Program Plann. 2008 May;31(2):191-8. https://doi.org/10.1016/j.evalprogplan.2008.02.005
https://doi.org/10.1016/j.evalprogplan.2...

Conclusion

Considering the high prevalence of dental caries, oral mucosal lesions, periodontal diseases, and reduced masticatory function among the elderly in Chile, the Preventive Oral Health Exam for Elderly People (EDePAM) proposed in this study will enable comprehensive assessment of their oral health and function, by providing accurate diagnoses of oral diseases. This, in turn, will enable more effective treatments to be provided, hence improving the quality of life of this segment of the population of the country.

Acknowledgments

We are grateful to all of the experts who participated in the e-Delphi rounds. All participants had the opportunity to review the content, and ultimately make their own contributions. Author JG was supported by a grant provided by the FONDEF I+D, ID #18I10034, and author MB was supported by Agencia Nacional de Investigación y Desarrollo / Programa Becas / Beca Doctorado Nacional/2018 – 21180023. The authors declare that they have no conflicts of interest related to this study.

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  • 44
    Hama Y, Kanazawa M, Minakuchi S, Uchida T, Sasaki Y. Reliability and validity of a quantitative color scale to evaluate masticatory performance using color-changeable chewing gum. J Med Dent Sci. 2014 Mar;61(1):1-6.
  • 45
    Kamiyama M, Kanazawa M, Fujinami Y, Minakuchi S. Validity and reliability of a Self-Implementable method to evaluate masticatory performance: use of color-changeable chewing gum and a color scale. J Prosthodont Res. 2010 Jan;54(1):24-8. https://doi.org/10.1016/j.jpor.2009.08.001
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    » https://doi.org/10.5051/jpis.2015.45.6.205
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    Leake JL. An index of chewing ability. J Public Health Dent. 1990;50(4):262-7. https://doi.org/10.1111/j.1752-7325.1990.tb02133.x
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Publication Dates

  • Publication in this collection
    14 Jan 2022
  • Date of issue
    2022

History

  • Received
    31 July 2020
  • Accepted
    6 June 2021
  • Reviewed
    15 Sept 2021
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