Der Einfluss der Mundgesundheit auf die Prognose stationärer älterer multimorbider Patienten und die Entwicklung eines Plans zur Integration der Zahnmedizin in die multiprofessionelle Versorgung der universitären Altersmedizin der Universitätsklinik Köln

Trotz eines zunehmenden Bewusstseins für die Notwendigkeit zahnärztlicher präventiver Versorgung bei älteren Menschen wird der Mundgesundheitsstatus in der klinischen Praxis sowie in der Denkweise und Ausbildung vieler medizinischer Fachkräfte immer noch weitgehend vernachlässigt. Gebrechliche und multimorbide ältere Menschen leiden häufig unter einer unzureichenden Mundgesundheitsversorgung, aber standardisierte zahnärztliche Untersuchungen werden in Kliniken nicht routinemäßig durchgeführt, obwohl dies ein Ort sein könnte, an dem ein zahnärztlicher Zugang leicht zu erreichen wäre. Vor dem Hintergrund der zunehmend wahrgenommenen Verflechtung mit der allgemeinen- und funktionellen Gesundheit bildet die Mundgesundheit (MG) aktuell einen „blinden Fleck“ in der Diagnostik und Therapie älterer Patienten. In dieser Dissertationsschrift wird auf Grundlage einer bereits in einem internationalen Fachjournal veröffentlichten Studie der Einfluss der MG auf die Prognose älterer und multimorbider Patienten untersucht und im Folgenden ein Plan zur Integration der Zahnmedizin in die multiprofessionelle Versorgung älterer Patienten entworfen. In der im Fachjournal European Geriatric Medicine erschienenen prospektiven Studie an 100 Patienten über 65 Jahre konnte gezeigt werden, dass der Mundgesundheitsstatus – gemessen anhand verschiedener Indizes (1. Kayser- Jones Brief Oral Health Status Examination (BOHSE); 2. Decayed, Missing, or Filled Teeth Index (DMFT); 3. Geriatric Oral Health Assessment Index (GOHAI)) – signifikant mit der individuellen Prognose älterer, multimorbider Patienten assoziiert ist, die anhand des Multidimensionalen Prognostischen Index (MPI) bestimmt wurde. Zudem zeigte sich im sechsmonatigen Follow Up, dass zahnärztliche Untersuchungen und Behandlungen trotz Behandlungsbedürftigkeit nur in geringem Maße in Anspruch genommen wurden. Die im zweiten Teil der Arbeit entworfene IntDENTgration Studie zielt darauf ab, einen möglichen Lösungsansatz für diese Versorgungslücke bei älteren, multimorbiden Patienten anzubieten. Mithilfe verschiedener MG-Screenings und -Fragebögen könnten bei dieser vulnerablen Patientengruppe relevante MG-Probleme während eines stationären Aufenthalts in der universitären Altersmedizin der Universitätsklinik Köln identifiziert werden. Durch eine individuelle Mundhygieneinstruktion soll die Gesundheitskompetenz gestärkt werden. Ein strukturierter Mundgesundheitsplan dient als Grundlage zur Verbesserung der MG. Um eine Anbindung an die ambulante zahnmedizinische Versorgung zu sichern, soll ein zusätzlicher Hauszahnarztbrief mit allen relevanten zahnmedizinischen Befunden inklusive Behandlungsempfehlung an den Hauszahnarzt geschickt werden und vor Entlassung ein Termin mit diesem abgesprochen werden. Das Ziel der Integration der Zahnmedizin in eine multiprofessionelle klinische Versorgung älterer Patienten ist die Sekundär- und Tertiärprävention oraler und systemisch-funktioneller Erkrankungen sowie die Verbesserung der individuellen Prognose

Outcomes of the Nonendoscopic Transoral Approach to Subcondylar Mandible Fractures

Purpose: The transoral approach (TRA) to subcondylar fractures without any endoscopic or transbuccal assistance is not a common technique. The purpose of this study was to measure and compare the quality of open reduction and internal fixation (ORIF) between the TRA and the retromandibular approach (RMB), including types and frequencies of postoperative complications. Methods: In our retrospective cohort study, we enrolled a sample of patients with displaced subcondylar mandible fractures treated by ORIF. The predictor was the approach mode: TRA or RMB. In postoperative computed tomography (CT) data sets, we measured the angles of the condylar process in relation to references: 1) midline, 2) lateral ramus border, and 3) posterior ramus border. The primary outcome variable was the reduction outcome, which was calculated as the difference between the total of all angles of the operated side and the non-affected side. Secondary outcomes were postoperative complications extracted from patients' files. Other variables were age, gender, number of plates, operation time and a modified AO trauma score. In bivariate analysis, we compared the outcome between both groups. Results: Sixty-four patients were included in total, with TRA performed in 50%. Patients with TRA were younger (31 vs 41, P = .003), and the trauma score was lower (1.9 vs 3.3, P < .001). Reduction outcome remained comparable between both techniques (mean 3.7 degrees for both, P = .92). Complication rates were similar, although facial nerve palsy was absent for TRA (0 vs 4, P = .039). Conclusion: We suggest TRA for selected patients with displaced, single fragmented subcondylar fractures. Reduction outcome shows a comparable exactness to RMB, while TRA is safer for the facial nerve. (C) 2021 The American Association of Oral and Maxillofacial Surgeons

Osteotomy speed, heat development, and bone structure influence by various piezoelectric systems-an in vitro study

Objectives The aim of this in vitro study was to evaluate osteotomy speed, heat development, and bone structure influence from osteotomies performed by various piezoelectric devices and insert tips. These devices and tips were compared among each other with regard to conventional rotatory and oscillating systems with special focus on the insert tip design and thickness. Material and methods The osteotomies were conducted on porcine ribs utilizing 12 different insert tips (straight and angulated) and three conventional systems. After time and temperature measurements, histological analysis was carried out. Light microscopy was used to evaluate the roughness of the osteotomic surface and to search for indications of thermal bone necrosis. A special software analyzing tool was employed to determine cutting width (mm) and debris (%). Results All piezoelectric tips created smooth cuts. Cutting widths in general were wider than the actual insert tip size with a tendency for narrow straight insert tips producing relatively wide osteotomies, whereas narrow angulated inserts produced relatively small osteotomies. None of the samples demonstrated distinct indication of necrosis. Overall, there was only a small amount of debris in all osteotomy gaps. Conventional rotatory saws were faster and created less heat compared to all tested piezoelectric systems. Straight tips proved faster osteotomy speed than angulated tips. Thin insert tips indicated to have a positive correlation to osteotomy time and performed faster than conventional microsaw. The average temperature rise was lower when using conventional systems, but critical exceeding temperatures were only observed in short-time exceptional cases. In general, temperature rise was less when using angulated inserts. Conclusion All tested tips are appropriate for bone surgery. Only small differences were found among the piezoelectric insert tips. Although conventional rotatory systems in general performed faster osteotomies, special designed and thin piezoelectric insert tips seem to have a positive influence on osteotomy speed. Ultimately, none of the tested devices or inserts combined all best features of speed, heat development, bone structure influence, and safety

Role of a multidimensional prognosis in-hospital monitoring for older patients with prolonged stay

Objectives: The Multidimensional Prognostic Index (MPI) is a prognostic tool-amongst others-validated for mortality, length of hospital stay (LHS) and rehospitalisation risk assessment. Like the Comprehensive Geriatric Assessment (CGA), the MPI is usually obtained at hospital admission and discharge, not during the hospital stay. The aim of the present study was to address the role of an additional CGA-based MPI measurement during hospitalisation as an indicator of real-time in-hospital changes. Study design and main outcome measures: Two-hundred consecutive multimorbid patients (128 M, 72 F, median age 75 (78-82)) admitted to an internal medicine ward of a German metropolitan university hospital prospectively underwent a CGA and a prognosis calculation using the MPI on admission and discharge. Seven to 10 days later, an intermediate assessment (IA) was performed for patients needing a longer stay. Results: The median LHS was 10 (6-19) days. As expected, patients who received an IA had poorer prognosis as measured by higher MPI values (P = .037) and a worse functional status at admission than patients who had a shorter stay (P = .025). In case of prolonged hospitalisation, significant changes in the MPI were detected between admission and IA, both in terms of improvement and deterioration (P < .001). Different overtime courses were observed during prolonged hospitalisation according to the severity of prognosis (P < .001). Conclusion: A CGA-based MPI evaluation during hospitalisation can be used as an objective instrument to detect changes in multidimensional health course. Prompt identification of the latter may enable quick tailored interventions to ensure overall better outcomes at and after discharge

Epithelial loss of mitochondrial oxidative phosphorylation leads to disturbed enamel and impaired dentin matrix formation in postnatal developed mouse incisor

The formation of dentin and enamel matrix depends on reciprocal interactions between epithelial-mesenchymal cells. To assess the role of mitochondrial function in amelogenesis and dentinogenesis, we studied postnatal incisor development in K320E-Twinkle(Epi) mice. In these mice, a loss of mitochondrial DNA (mtDNA), followed by a severe defect in the oxidative phosphorylation system is induced specifically in Keratin 14 (K14+) expressing epithelial cells. Histochemical staining showed severe reduction of cytochrome c oxidase activity only in K14+epithelial cells. In mutant incisors, H&E staining showed severe defects in the ameloblasts, in the epithelial cells of the stratum intermedium and the papillary cell layer, but also a disturbed odontoblast layer. The lack of amelogenin in the enamel matrix of K320E-Twinkle(Epi) mice indicated that defective ameloblasts are not able to form extracellular enamel matrix proteins. In comparison to control incisors, von Kossa staining showed enamel biomineralization defects and dentin matrix impairment. In mutant incisor, TUNEL staining and ultrastructural analyses revealed differentiation defects, while in hair follicle cells apoptosis is prevalent. We concluded that mitochondrial oxidative phosphorylation in epithelial cells of the developed incisor is required for Ca2+homeostasis to regulate the formation of enamel matrix and induce the differentiation of ectomesenchymal cells into odontoblasts

The impact of oral health on prognosis of older multimorbid inpatients: the 6-month follow up MPI oral health study (MPIOH)

Purpose There is clear evidence for an association between oral health and systemic illnesses, geriatric syndromes, and mortality. Frail and multimorbid older people often suffer from insufficient oral health care, but standardized dental examinations are not routinely performed in clinical settings. The aim of this study was to verify the practicability of in-hospital oral health examinations and to identify their association with patients' prognosis as assessed by means of the Comprehensive Geriatric Assessment (CGA)-based Multidimensional Prognostic Index (MPI). Methods One hundred hospitalized patients aged 65 years and older (mean age 76.9 years (SD 6.4); 58.2% male, 41.8% female) underwent a CGA-based MPI calculation at discharge with subdivision into three mortality risk groups (MPI-1, low risk, score 0-0.33; MPI-2, moderate risk, score 0.34-0.66; MPI-3, high risk, score 0.67-1). To identify the current oral health status and the Oral Health-related Quality of Life (OHRQoL), three oral health examinations were performed. Information on survival, the incidence of oral diseases, dental appointments, and treatments up to 6 months after discharge were collected. Results All oral health examinations were feasible during hospitalization and were associated with MPI prognosis, even though they were not associated with 6-month mortality. The MPI could not predict the use of dental health care or treatment, as, irrespective of MPI and oral health examinations, dental services were underutilized during follow up. Conclusion Besides MPI evaluation, oral health examinations should be implemented into an inhospital course to improve clinical decision-making as well as secondary and tertiary prevention of oral health- and related systemic diseases. Key summary pointsAim To identifying tools for the reliable and systematic evaluation of oral health in older inpatients as well as to addressing the association between oral health and patients' prognosis as measured by the Comprehensive Geriatric Assessment (CGA)-based Multidimensional Prognostic Index (MPI). Findings Valid oral health examinations can be performed in older inpatients and are associated with individual multidimensional prognosis. Message Oral health should be assessed and incorporated into clinical decisions to improve patients' prognosis and prevention