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Satellite meeting in Gothenburg held by the EuropeanCollege of Gerodontology (ECG), the ProsthodonticResearch Group (PRG) and Geriatric Oral ResearchGroup (GORG) of the IADROn June 23rd and 24th 2003 the European Collegeof Gerodontology (ECG), the ProsthodonticResearch Group (PRG) and the Geriatric OralResearch Group (GORG) held a joint satellitemeeting to the General Assembly of the IADR atthe Riverton Hotel in Gothenburg under thePresidency of Angus Walls from Newcastle-upon-Tyne. Thanks are due to Dentsply for their generoussponsoring which made the event possible. Around90 colleagues from the three different groupsattended the meeting and enjoyed 11⁄2 daysscientific programme with lively and fruitfuldiscussions. Thirteen speakers from six countriesand three continents covered the main topics “Carepathways”, “Pharmacology for the older person”and “Oral Health and Quality of Life”. In a jointeffort with the presenters the proceedings aresummarised below.

Anne Sanders (Adelaide, Australia) approachedthe topic “What affects oral health-related qualityof life?” using Wilson and Cleary’s 1995 theoreticalmodel for quality of life. Previous adaptations ofthis model in the oral health literature have omittedthe social and psychosocial pathways hypothesisedto link disease to impaired quality of life. A keytheme in this presentation was that oral health-related quality of life (OHRQoL) is affected bycontextual factors upstream from health behaviourand dental service provision. Anne used self-reported data obtained from a national survey inAustralia to demonstrate empirically theassociations presented in the theoretical model.OHRQoL was evaluated using the short-form OralHealth Impact Profile (OHIP-14). In multivariatemodels, social support, stress and life satisfactionexplained more variation in mean OHIP-14 scoresthan did the combined effects of socio-demographic factors and tooth loss. Findingssupported the theoretical model and help toimprove the understanding of the mechanismsunderlying variation in population OHRQoL.

Finbarr Allen (Cork, Ireland) addressed thequestion “What is Oral Health-Related Quality ofLife?” in his comprehensive overview. Hedescribed a number of oral-specific health statusmeasures of varying sophistication which havebeen developed in order to improve the validity ofpatient-based assessment of oral disorders. Twoof these, the Oral Health Impact Profile (OHIP)and the Geriatric Oral Health Assessment Index

(GOHAI) were developed for use with older adults.Potential benefits of such oral health statusmeasures include identification of sub-groupswithin the population requiring care, monitoring“at risk” groups, targeting of financial resourcesand monitoring outcomes of clinical interventions.At the present time, oral health status measureshave mainly been used in descriptive populationstudies, predominantly in older adults. There havebeen fewer reports of the use of oral health statusmeasures in clinical trials where change in acondition following clinical intervention is theoutcome of interest. The challenges for the futureinclude: improving the properties of the availablemeasures, improving our understanding ofmeasurement of change and the development ofinternational collaborative research to facilitatebetween country comparison of research data.

Jocelyne Feine (McGill, Montreal, Canada)reported on the results of an analysis designed todetermine the cost-effectiveness of mandibulartwo-implant overdentures and conventionaldentures opposed by conventional maxillarydentures. Direct treatment costs (e.g. materials andlabour) and oral health-related quality of life usingthe OHIP-20 were measured in edentulous seniors(65-75 years; n=30) who received a maxillarydenture and either a mandibular conventionaldenture (CD) or a two-implant overdenture withball attachments (IOD) up to one year post-treatment. Data for subsequent years wereestimated from values obtained from publisheddata and a panel of experts. Using an average lifeexpectancy of 17.9 years, the equalized annualcosts were CAD$ 398.60 for CD and CAD$ 528.40for IOD (p<0.001). The equalized annual valuesfor the OHIP-20 outcome were 47.01 units for CDand 31.29 for IOD treatment (p<0.05), indicatingthat oral health-related quality of life wassignificantly better (by 34%) in the IOD group.Although the initial cost of mandibular two-implantoverdentures is significantly more thanconventional dentures, the former provide a muchbetter oral health-related quality of life. Bycomparing costs and benefits over the expectedlifetime of the subjects, it can be seen that oralhealth-related quality of life can be greatlyimproved by IOD treatment for a relatively modestannual investment.

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Jimmy Steele (Newcastle-upon-Tyne UK)reminded the audience how much we have learnedabout oral health-related quality of life and how tomeasure it in older people. Although a number ofvalid instruments have been developed, not all ofthese have been designed or validated for theelderly. Those that have, illustrated how age,disease and various social variables influence oralhealth-related quality of life. Despite theconsiderable knowledge base that has beenestablished, there remain large gaps in ourknowledge. We do not yet fully understand therelative contribution of oral health to quality oflife compared with other aspects of health. Littleis known about those at the severe end of thespectrum, nor do we know a great deal about thepositive, life enhancing, aspects of good oral healthin older adults and how they affect older adults.

Above all, whilst we know quite a lot aboutpopulations, we know little about how oral health-related quality of life may change at an individuallevel. It is the use of such quality of life indices tomeasure change, specifically to measure theoutcomes of interventions designed to improve oralhealth or the cost-effectiveness of care in olderadults, which still holds great opportunities forresearchers. The importance of now using theseinstruments in the most appropriate ways wasoutlined. Rather than continually testing andretesting the tools on populations, we now need tostart to use them to help build evidence-basedpractice, based on the outcomes that matter forolder people.

Jimmy Steele’s presentation opened the meetingfor general discussion led by Mark Thomason(Newcastle-upon-Tyne, UK). The discussionranged through the choice of instruments fordifferent populations and the advantages of shortquestionnaires for compliance and longer ones forspecific detail. The majority of the discussioncentred around the use of OHIP as an outcomevariable and our current understanding of what oneOHIP point represents and the relationship betweenthis and the cost of achieving improvements inOHIP scores with treatment.

Rita Isaksson (Sweden) presented her studies onoral treatment intention and realistic oral treatmentneed for patients in long-term care in Sweden. Herfirst aim was to evaluate the clinical oral healthoutcome in care receivers, by using an oral healthscreening protocol, after the caregivers hadundergone a one-session, four-hour oral healtheducation programme. Her second aim was toevaluate the realistic oral treatment need, takinginto consideration the treatment intention. One

hundred and seventy subjects enrolled in municipallong-term care were included into the first part ofthe study, and were available for examination bothbefore and 3-4 months after the education of thecaregivers. The second study comprised a sample,of 866 persons in long-term care. The resultsshowed that a limited oral health education, offeredto caregivers within long-term care facilities, hada positive impact on residents’ oral health status.Further, it showed that the realistic oral treatmentneed, guided by the examiners’ estimation of theappropriate treatment intention, was quite modestin this population; 61% had a need for oral/dentaltreatment, 31% to be accomplished by prophylaxisand 30% by reparative/urgent measures. Only 1%were estimated to be in urgent need.

Christine Ritchie (Kentucky, USA) shared someof her impressively comprehensive medicalbackground in gero-pharmacology. She reportedthat the average older adult uses between four andeight medications concurrently. Many medicationsprescribed for older adults are unsuitable becauseof physiological changes that occur with ageingor because of concomitant conditions or drugs thatare incompatible with the prescribed medication.Physiological changes that occur with ageinginclude a decrease in lean body mass with a relativeincrease in fat mass, a decrease in hepatic oxidativemetabolism through the cytochrome P450 system,resulting in a decreased clearance of drugs, and adecrease in renal function. Adverse drug reactionsare more common in older adults and are associatedwith the use of greater numbers of medications.Warfarin is associated with many drug-drug anddrug-food interactions. Individuals with cognitiveimpairment are more likely to develop adversereactions to medications with psychotropic effects.These drugs are also associated with an increasedlevel of falls. She concluded that critical issues inmedication management in older adults include thefollowing:

1. Obtain a complete drug history, includingherbs and non-prescription drugs.

2. Avoid medications if benefit is marginalor if non-pharmacologic alternatives exist.

3. Consider the cost.

4. Use appropriate doses.

5. Keep regimen as simple as possible.

6. Write instructions out clearly.

7. Insure understanding and adequate cognition.

8. Have patient bring in medications ateach visit.

9. Monitor/ask regarding adverse drug reactions

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The topic of polypharmacy was also addressedby Timo Närhi (Turku, Finland) who focused onsalivary flow and function. After his descriptionof the physiological function of saliva and itsbiochemical composition he described the age-related structural changes in the salivary glands aswell as the functional changes in the saliva flowrate and composition. Clinical signs ofhyposalivation comprised changes in the lips andcorner of the mouth (dry lips, angular cheilitis),changes in the oral mucosa (candidosis,erythematous or pseudomembranous surface) andtongue (fissuring, lobulation, candidosis) as wellas changes in the dentition (increased prevalenceof caries and tooth erosion, fractures in the enamel),changes in the appearance of the saliva (difficultto “milk” from parotid gland, thicker consistency,bubbly and foamy appearance) and swelling of thesalivary glands. He further stated that more than400 drugs are known to cause hyposalivation and/or xerostomia and as a side effect and demonstrateda significant correlation between the salivary flowrate and the number of medications taken by anelderly person. Treatment options comprisedmechanical and gustatory stimulation but alsosalivary substitution. Systemic stimulation was notrecommended for the elderly with multiplemedications. To prevent oral disease herecommended the use of supplemental electrolytes,healthy dietary habits as well as clear oral hygieneinstructions.

Anne Maguire (Newcastle-upon-Tyne, UK)addressed the problem of sugar in medicines,particularly in medicines with prolonged oralclearance. She discussed why medicines areformulated with sugar, the extent of use of thesetypes of medicines in older people and how theway in which we prescribe these medicines impactsupon their sugar content. Anne presented data fromher work which investigated whether healthprofessionals consider the use of sugar-freemedicines in older people a health issue and thenconcluded with some recent work on the erosivepotential of medication showing that sugar contentdoes not affect the erosive potential of a medicinein-vitro and that more accurate predictors are drugstrength, therapeutic group, dose form and whethera medicine is branded or generic. Her presentationcontained unique data of its type and again flags anew area for vigilance for us all. With 24% ofprescriptions used in older people havingprolonged oral clearance and generic prescribingmore likely to result in sugar-containing medicinesbeing dispensed we need to address these issueswith both colleagues and patients. We also need

more information on an international basis to seeif this is a problem for the UK alone or whetherthere is once again an international dimension.Furthermore, we need to consider extending thecampaign for prescribing sugar-free medicinesfrom children to all adults. The final and perhapsmost important take-home message of all is theeducation of our medical and pharmacistcolleagues about the potential oral health effectsof sugar in medicines on dental health in adults aswell as children.

Management of caries using ozone was the topicof the presentation of Edward Lynch (Belfast, UK).He showed that patients accept this new ozonetreatment method very easily and supported thisstatement by a comprehensive overview ofresearch data as well as clinical pictures. He citedFreeman who had reported a general practice studyof 277 patients where 100% of the patients wouldlike to receive this treatment again. This simplefast novel method avoids the need for localanaesthesia, drilling and filling and thus fulfils theprofessions wildest dreams and helps many olderpeople. It has been successfully researched in 15UK sites as well and numerous sites internationally,all of whom have reported significant reversal ofcaries. Ozone readily penetrates through decayedtissue, eliminating any bacteria, fungi and viralcontamination, eliminating the ecological niche ofcariogenic microorganisms as well as priming thecarious tissue for remineralisation. He concludedthat remineralised lesions are the ideal “fillingmaterials” as reversed lesions are more resistantto future decay than sound tooth tissue. AylinBaysan showed that for root caries 99% ofmicroorganisms are eliminated with just a singleprofessional 10 seconds of treatment with ozone;over 97% of lesions clinically reverse, and theremainder do not progress, with follow-up periodsof 12 months. More than one million patients havealready been treated in the UK alone andworldwide not a single side-effect has ever beenrecorded.

An elaborate summary/discussion was presentedby Linda Niessen (Dentsply, USA). The oralscientific programme was complemented by anumber of high quality poster presentations. I hopethese summaries give you an insight of the highquality presentations and the comprehensivecoverage of health care issues in the elderlypopulation.

To further encourage young investigators tofocus their interest on the health issues of theelderly population GABA sponsored for the firsttime the “European College of Gerodontology –

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GABA Research Award”. This was endowed witha plaque and a prize of CHF 5000.00. The winnerswere Hanna Hüpsch-Marzec and her collaboratorsWojciech Pluskiewicz and Leszek Ilewicz from theDepartment of Conservative Dentistry andPeriodontal Diseases as well as the Department ofMetabolic Diseases at the Silesian MedicalAcademy, Poland, for their poster presentationentitled “Study of connections of values of chosenparameters obtained in clinical, radiological,densitometrical and biochemical examinations ofpostmenopausal women”. The picture showsHanna with the President of the ECG, Angus Wallsand Beate Helling from GABA research (Photo 1).The prize was presented during the splendidconference dinner. Another highlight during thedinner was the speech by Gunnar Carlsson, whosummarised the events of the day with hislegendary scintillatingly witty poems. Last but not

least I would like to mention, that the ECG hasoffered Ejvind Budtz-Jørgensen from theUniversity of Geneva, Switzerland, HonoraryMembership for his outstanding contribution to thescience, clinical practice and teaching inGerodontology over many years (Photo 2). Theceremony was complemented by a speech fromthe first ECG Honorary member Poul Holm-Pedersen (Copenhagen, Denmark) who detailedEjvind’s contribution to Gerodontology startingwith their common past at the Danish Boy Scouts.

Altogether the meeting was a very successful,interesting and inspiring event which not onlyallowed for the exchange and discussion ofknowledge, experience and research findings, butalso for a social gathering with “old” and “new”friends and the enjoyment of the splendidsurroundings of the Gothenburg area.

Frauke Müller (Secretary ECG)and the speakers of the meeting

Photo 2 Honorary Membership was awarded to Professor Ejvind Budtz-Jørgensen (middle), by the President, Professor Angus Walls (right) and thefirst Honorary Member, Professor Poul Holm-Pedersen (left).

Photo 1 The European College of Gerodontology GABA Research Awardis handed over to the winner, Dr Hanna Hüpsch-Marzec (left), by thePresident, Professor Angus Walls (right) and Dr Beate Helling from GABAResearch (middle).

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