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Treatment Outcomes of Oral Diseases in Medically Complex Patients

Center for Clinical Research
Division of Extramural Research


OBJECTIVE: 

Many approaches are used to prevent and treat oral diseases and conditions.  Most evidence supporting these therapies derives from clinical trials/studies that enrolled healthy subjects despite consistent findings that oral diseases are frequently more severe in selected patient groups.  The objective of this initiative is to stimulate research to determine outcomes of prevention and treatment strategies for oral diseases in persons with complex medical conditions complicating oral health, and to provide insight into the pathobiology of reported higher treatment failure rates. Comparative effectiveness studies of dental procedures or reconstructive interventions using retrospective analyses of existing records, database analyses or prospective longitudinal studies of selected patients groups could provide evidence to inform patients who must pay for their oral health care and providers who recommend treatment options.

BACKGROUND:

Many systemic diseases are associated with compromised oral health including diabetes, Sjögren’s syndrome, head and neck cancers, cleft lip/palate and Ectodermal Dysplasia (ED).  Oral diseases are more concentrated in these patient groups. Unfortunately, the long term successes of different prevention strategies, treatments and restorative approaches have not been assessed in these compromised individuals.  Patients with these diseases often spend significant time and resources maintaining their oral health. A recent case-control study of 547 primary Sjögren’s syndrome patients found out-of-pocket spending for dental care was two to three fold higher in Sjögren’s patients as compared with a peer control group.  A survey of 24 ED patients found over 50% paid for dental services out of pocket, and found costs for dental treatment ranged from $2,038 to $3,298 for those who had received prosthodontic treatment only and from $12,632 to $41,146 for those who had received a combination of prosthodontic, orthodontic and implant treatment. 

Studies suggest traditional treatments for dental caries frequently fail in patients with low salivary output.  A small two-year cohort study of glass ionomer and composite restorations placed in Class V lesions of head-and-neck irradiated cancer patients found 17 to 40% failed at 6 months, and 48 to 96% failed by 24 months.  These rates were independent of topical fluoride use. Other studies suggest topical fluoride gels, the most frequently recommended caries preventive agent for patients with severe salivary hypofunction, negatively influence glass ionomer cements.  Children with Ectodermal Dysplasias and tooth agenesis often have dental implants placed before age 18 years.  A recent review of the literature on dental implants in patients with ED and tooth agenesis concluded that evidence to support treatment guidelines was scarce, and that the studies lack long term outcomes.  A recent survey of 109 ED patients with implants reported 50% implant or prosthetic complications following implant treatment, and 24% reported some type of failure.   Children born with oral clefts have multiple dental procedures from age 1 year through early adulthood.  There is little evidence to support the effectiveness of these procedures.  For example, it is not known whether the difficult and expensive naso-alveolar molding technique for children with oral clefts improves long-term treatment outcomes. 

There is insufficient evidence to formulate prevention and treatment guidelines for almost all medically complex patient groups with compromised oral health.  Further, there is insufficient understanding of the higher treatment failure rates, such as the higher restorative failure rates in individuals with severe salivary hypofunction.  There has been almost no comparative effectiveness research with these patient groups that identifies procedures, devices, and drugs that could reduce cost or patient inconvenience without diminishing oral health.

 

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This page last updated: February 26, 2014