10.59987/ads/2011.3-4.25-30
This study is concerned with the educational intervention layout proposed as a possible answer for the disparities in healthcare services for disabled persons. Material and methods. The data sampling was performed on individuals in Rome, affected by psychophysical disabilities, living in residential care facilities. Participants were randomly divided into two groups: Study and Control Group, consisting of patients who did or did not participate in the Educational Phase. All the caregivers participated in an educational course. Screening period: September 2008 – March 2009. Examinations were performed using Visible Plaque Index (VPI), Gingival Bleeding Index (GBI) and Microbiological Analysis.
Results. The total number of patients utilized for the study was 36 (18 in each group). The final sample amounted to 70% (14/20) in the Study Group and to 75% (15/20) in the Control Group. In both examined groups Oral Hygiene, Gingival Health State and Microbiological Analysis show an overall improvement of the indices, compared with the initial status, mostly at a follow-up after 4 weeks. However, Study Group show a significantly better improvement. Conversely, after 6 months the overall clinical indices worsened again.
Conclusion. The difference in the significant improvements of the groups, even if only over a short-time evaluation, endorses that the participation of the patients as well as tutors in the educational phase is an effective strategy for the short-term.
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Disabled patients and oral health in Rome, Italy: long-term evaluation of educational initiatives
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Disabled patients and oral health in Rome, Italy: long-term evaluation of educational initiatives
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                                                                                                                Original article



    Disabled patients and oral health in Rome, Italy:
    long-term evaluation of educational initiatives




                                                                                                                  li
                                                                                                               na
    Laura Avenali, DDS                                              Background
    Fabrizio Guerra, MD, DDS, PhD                                   The body of literature speaking to oral health (OH) initia-
    Luigi Cipriano, DDS                                             tives throughout Europe is vast and often country speci-




                                                                                                            io
    Denise Corridore, DDS                                           fic. Sometimes this makes it difficult for policy makers and
    Livia Ottolenghi, DDS                                           researchers alike to see the benefits of work done in one
                                                                    country applied to their own context. This is not so diffe-




                                                                                     az
                                                                    rent from the experience in the United States where re-
    “Sapienza” University of Rome, Rome, Italy                      search done in each state has to take into consideration
    Department of Oral and Maxillofacial Sciences                   specific social and economic factors. Thanks to two im-
    Preventive and Community Dentistry                              portant initiatives undertaken in this last decade, it has been
                                                                    possible to go beyond the differences, to construct a com-




                                                                                   rn
                                                                    mon framework and orientation for research in Oral He-
    Corresponding author:                                           alth everywhere in the world. The U.S. Department of He-
    Dott. Denise Corridore                                          alth and Human Services (2), and the World Health Or-
    Department of Oral and Maxillofacial Sciences                   ganization produced important guidelines, some of which




                                                                        te
    Via Caserta, 6 - 00161 Rome, Italy                              he authors of this study used. They are as follows:
    Phone: +390649976642
    E-mail: denise.corridore@gmail.com                              U.S. DEPARTMENT OF HEALTH
                                                                In  AND HUMAN SERVICES
                                                                    • Oral health is more than healthy teeth.
    Summary                                                         • Oral diseases and disorders in and of themselves af-
                                                                       fect health and well-being throughout life.
    This study is concerned with the educational inter-             • The mouth reflects general health and well-being.
                                                   ni
    vention layout proposed as a possible answer for the            • Oral diseases and conditions are associated with other
    disparities in healthcare services for disabled persons.           health problems.
    Material and methods. The data sampling was per-                • Safe and effective measures exist to prevent the most
                                            io

    formed on individuals in Rome, affected by psycho-                 common dental diseases–dental caries and periodontal
    physical disabilities, living in residential care facilities.      diseases.
    Participants were randomly divided into two groups:
    Study and Control Group, consisting of patients who
                                   iz



                                                                    WORLD HEATH ORGANIZATION
    did or did not participate in the Educational Phase. All        • (available at http://www.who.int/oral_health/objecti-
    the caregivers participated in an educational course.             ves/en/index.html)
    Screening period: September 2008 – March 2009. Exa-             • Greater emphasis is put on developing global policies
                  Ed




    minations were performed using Visible Plaque Index               in oral health promotion and oral disease prevention
    (VPI), Gingival Bleeding Index (GBI) and Microbiolo-            • Oral health is part of total health and essential to qua-
    gical Analysis.                                                   lity of life…
    Results. The total number of patients utilized for the          • There must be a priority given to integration of oral he-
    study was 36 (18 in each group). The final sample                 alth with general health programs at community and
    amounted to 70% (14/20) in the Study Group and to                 national levels
 IC




    75% (15/20) in the Control Group. In both examined
    groups Oral Hygiene, Gingival Health State and Mi-              Development of community empowerment strategies are
    crobiological Analysis show an overall improvement              essential. Over the last decades, there have been many
    of the indices, compared with the initial status, mostly        significant studies documenting the inequities around the
C




    at a follow-up after 4 weeks. However, Study Group              world between oral health care (OH) for individuals with
    show a significantly better improvement. Conversely,            disabilities and that provided for the general public. The-
    after 6 months the overall clinical indices worsened            se studies have contributed to a more complete under-
    again.                                                          standing of: 1) the OH diseases prevalent among disabled
©




    Conclusion. The difference in the significant impro-            patients; 2) their possible causes; 3) possible discrepan-
    vements of the groups, even if only over a short-time           cies in care. The majority of data to date has indicated the
    evaluation, endorses that the participation of the pa-          following:
    tients as well as tutors in the educational phase is an
    effective strategy for the short-term.                          Disease profile of disabled patients: more frequent oral
                                                                    diseases among disabled patients are periodontal disea-
    Key words: oral health, oral diseases, disabilities, di-        se (3-7) and carious disease (8-9), but there are also ca-
    sabled patients.                                                ses of abnormal eruption and abnormal tooth development

    Annali di Stomatologia 2011; II (3-4): 25-30                                                                                25
    L. Avenali et al.


    (10-14), diseases of the oral mucosa (5), changes in oc-          ticipate in the Educational Phase. Each group was made
    clusion and masticatory function (5,10,15). For effective pre-    up of 20 people.
    vention and therapeutic interventions, studies have hi-           Though the patients were of legal age, it was not possi-
    ghlighted the need to consider patients’: type of disease,        ble for ethical reasons to construct a project whereby any
    systemic status, and the specific needs that might arise          of these patients would be studied without being accom-
    due to the particular patient profile (13,14,19,25,30).           panied by a tutor. Therefore, patient Tutors from both groups




                                                                                                                    li
    Possible causes of discrepancies in levels of care for            participated in the Educational Phase.
    disabled patients: many studies pointed to unequal ac-




                                                                                                                 na
    cess to care, which was tied to a host of underlying ele-         Screening period and data collection
    ments, including: economic factors, lack of information, phy-     Screening period: September 2008 – March 2009.
    sical/structural obstacles inherent to the institutions them-     There were 3 sampling periods: T0 ,T1, T2 .
    selves, and inadequate preparation of health personnel




                                                                                                              io
    (19,31,37).                                                       T0 : first meeting for collection of data and educational en-
    Other factors contributing to a worse state of OH                 counters with patients and tutors.
    among disabled: low or absent self-sufficiency (16), phar-        T1 : Follow-up after 4 weeks
    macological therapies (17,21) and particular systemic and         T2 : Follow-up after 6 months




                                                                                       az
    oro-facial features (10,22,24).
                                                                      The study was divided into two phases:
    Most of the studies concurred about the two primary are-
    as of intervention: 1) Education: prescribing increased dis-      Phase 1 (T0): Educational encounters – duration 20 mi-




                                                                                     rn
    semination of information regarding OH (prevention and            nutes; and collection of data regarding clinical and mi-
    cure) to disabled patients and their caregivers: 2) Access        crobiological parameters
    to Services: proposing careful analysis of possible barriers      Phase 2 (T1, T2): Follow-up analysis of clinical and mi-
    (architectonic and cultural) to services for OH prevention        crobiological parameters at 4 weeks (T1) and 6 months




                                                                          te
    and cure for disabled patients.                                   (T2).

                                                                      Examiners were trained on data collection and the taking of
    Aim of study                                                      microbiological samples. Calibration included training ses-
                                                                  In  sions, actually data/sample collection, and a discus-
    This study is concerned with the educational interventions        sion/comparison of results. These sessions were comprised
    proposed by many studies as a possible area of inter-             of a randomly selected group of 20 adult out-patients of the
    vention for the disparities in healthcare services. Though        Oral and Maxillo-Facial Sciences Department of Sapienza
    they seemed to be pointing in a positive direction, few fol-      University of Rome. They were divided into two groups of 10.
                                                    ni

    low-up studies have been performed to evaluate these pro-         The inter-examiner agreement was equal to 95%.
    grams over the long-term. The aim of this study is to eva-
    luate the efficacy of educational programs targeted to di-        Intervention
                                          io


    sabled patients and their tutors (or healthcare professio-        T0 educational meetings with a duration of 20 minutes were
    nals who assist them) over time.                                  organized for Study Group patients and for tutors of both
                                                                      groups (Study Group and Control Group). Audiovisual de-
                                 iz



                                                                      vices and models for simulation developed by a professor
    Materials and Methods                                             of Sapienza University, Rome were used. Then all patients
                                                                      underwent clinical examinations for the collection of data
                 Ed




    Population studied - sampling                                     pertaining to the Visible Plaque Index (VPI) and Gingival
    The data sampling was performed on individuals in                 Bleeding Index (GBI) (Ainamo and Bay) (39).
    Rome, Italy, affected by psychophysical disabilities, living      Both clinical indices had Presence/Absence values and
    in residential care facilities with 24/7 professional assi-       were chosen because of their optimal speed of execution
    stance. In Italy, these particular structures providing care      and adaptability to a wide range of compliance levels
    to disabled residents are called “Protected Residences” and       among subjects.
    are fully covered by the National Health Service.                 The measurement of the Visible Plaque Index (VPI), ex-
 IC




    The residences selected for this study are situated in the        pression of oral hygiene status, was based on the detec-
    Municipality of Rome, Italy. They belong to the Association       tion of the presence (positive value) of plaque clinically vi-
    called “Coop. Soc. Progetto ‘96”, that has been working sin-      sible on the buccal, oral and interproximal surfaces of the
    ce 1999. They are part of a Protected Residential Project,        teeth. The plaque had to be visible by all the examiners and
C




    which focuses on providing a positive and motivational en-        by the patient being examined (optimally), in accordance
    vironment to disabled individuals who can no longer live          with the recommendations of Ainamo and Bay (39).
    at home and have a tutor/patients ratio is 1/5.                   The Gingival Bleeding Index (GBI), primary clinical ex-
    The selection criterion for this study was age. All individuals   pression of the gingival inflammation, was evaluated by de-
©




    older than 18 living in the above-mentioned residences            tecting the presence or absence of bleeding after pro-
    were included (n = 40). No other inclusion or exclusion cri-      bing/pressing the examined gingival parts. A PDT Sensor®
    teria was used. Participants were randomly divided into two       periodontal probe (probe made of plastic resin with high
    groups: 1) Study Group, consisting of patients who parti-         degree of flexibility and whose control device has probing
    cipated in the educational phase regarding direct hygie-          force equal to 20 g) was placed into the gingival sulcus or
    ne and oral health using didactic materials designed by the       periodontal pocket, parallel to the tooth’s long axis. The
    Dept. of Oral Health Science (Sapienza University, Rome).         bleeding that appeared within 10 seconds was registered
    2) Control Group, consisting of patients who did not par-         as positive value.

    26                                                                                    Annali di Stomatologia 2011; II (3-4): 25-30
    Disabled patients and oral health in Rome, Italy: long-term evaluation of educational initiatives


    Furthermore, microbiological analysis was made, utilizing
    the Real-Time PCR (GABA International - meridol® Pe-
    rio Diagnostics) (40), for the quantitative calculation of six
    bacteria which are markers of periodontitis and of total bac-
    terial load. The bacterial strains identified which are mar-
    kers for periodontitis were the following: Actinobacillus ac-




                                                                                                                  li
    tinomycetemcomitans, Porphyromonas gingivalis, Tan-
    nerella forsythensis, Treponema denticola, Fusobacterium




                                                                                                               na
    nucleatum ssp., Prevotella intermedia.
    After sampling, the sub-gingival plaque samples were pla-
    ced in into the pipettes provided and were sent in the ori-
    ginal package for the Real-Time PCR analysis, according




                                                                                                            io
    to the meridol® Perio Diagnostics protocol.
    The results were obtained one week after the samples had
    been received by GABA meridol® Perio Diagnostics la-
    boratory.




                                                                                       az
    In Phase 2, all patients underwent the same clinical and
    microbiological exams according to the same parameters
    during the initial data collection Phase.




                                                                                     rn
    Data Analysis
    The collected data were stored using the Microsoft Excel         Figure 1 - Flow of participants.
    (Windows XP) program and the statistical analyses were
    performed with SPSS version 10, 2000 (SPSS Software




                                                                         te
    - Chicago).                                                      Table 1 - Characteristics of the Final Sample (T2).
    The first step in the data analysis was a unvaried statisti-
    cal processing, consisting of a descriptive analysis of data.
    The following step was the evaluation of the dependence
    between the considered variables, using Pearson Chi-squa-
                                                                 In
    re test. The comparison between the bacterial loads of the
    two groups was performed with the Mann-Whitney non-
    parametric test. As is standard, the level of significance for
    both tests was set equal to 0.05.
                                                    ni

    Results                                                          Table 2 - Clinical Indices.
                                            io


    During the early phases of the project, two patients from
    each group were not compliant. Therefore, the total num-
                                   iz



    ber of patients involved for the study was 36 (18 in each
    group). Also, due to personal problems, some patients were
    unable to participate in all tests. The final sample amoun-
                  Ed




    ted to 70% (14/20) in the Study Group and to 75% (15/20)
    in the Control Group (Fig. 1). At T2, mean age in the Stu-
    dy Group was 31.9 years old, and in the Control Group was
    41.6 years old. (Tab. 1).

    Oral Hygiene and Gingival Health
    Tab. 2 - Shows the Visible Plaque Index (VPI) and the Gin-
 IC




    gival Bleeding Index (GBI) values for groups and phases.         Microbiologic Analysis: T1, the Real-Time PCR microbio-
                                                                     logical analysis showed an overall quantitative reduction
    Visible Plaque Index (VPI) results: T1: compared to the ini-     of the total bacterial load in both groups.
    tial phase, the VPI values were lower at this phase, both        At T2 the total bacterial load is further reduced in the Stu-
C




    in the Study Group and in the Control Group, with a si-          dy Group and instead remains constant in the Control
    gnificant difference between the two groups.                     Group; in both cases the values show a significant diffe-
    T2, the values of positive VPI are higher than T1, but lower     rence between the two groups (Fig. 2). Regarding bacte-
    than the values in the initial phase; also in this case the-     ria marker (Tab.3), the qualitative analysis showed at T1
©




    re is a significant difference between the two groups.           a reduction of all the bacterial strains in both groups, ex-
                                                                     cept for the Fusobacterium nucleatum’s value, which shows
    Gingival Bleeding Index (GBI): T1 this parameter shows a         a slight quantitative increase in the Control Group.
    significant improvement only within groups.                      At T2 the analysis indicates: (i) Study Group a reduction,
    Instead, at T2 the indices are similar to the values recor-      compared with T1 of all the bacteria, except Actinobacil-
    ded at T0 , especially in the Control Group; however, the-       lus actinomycetemcomitans and Fusobacterium nuclea-
    re was no significant difference in this phase between the       tum. Compared with T0 all the bacterial strains are redu-
    two groups.                                                      ced, except Actinobacillus actinomycetemcomitans; (ii)

    Annali di Stomatologia 2011; II (3-4): 25-30                                                                               27
    L. Avenali et al.


                                                                     CONTROL GROUP (patients who did not attend the edu-
                                                                     cational program).
                                                                     In the Control Group, both clinical and microbiological va-
                                                                     lues decreased after one month (even if less significan-
                                                                     tly than the first group) and returned to initial values af-
                                                                     ter 6 months.




                                                                                                                    li
                                                                                                                 na
                                                                     Therefore the most important observation concerns the cli-
                                                                     nical and qualitative/quantitative parameters of the oral bio-
                                                                     film: its clinical indices, its total load and its pathogen-
                                                                     periodontal bacteria decreased more in the Study Group
                                                                     than in the Control Group. This was the case in both fol-




                                                                                                              io
    Figure 2 - Total bacterial load.                                 low up periods T1 and T2.
                                                                     As a result, our data indicates that utilizing a structured edu-
                                                                     cational program for disabled patients together with their
    Control Group, compared with T1 all the bacterial markers




                                                                                      az
                                                                     tutors (i.e. caregivers) can improve both their oral health
    are increased, except Fusobacterium nucleatum. Com-              habits and the qualitative properties of bacterial plaque,
    pared with T0 all the values are increased, except for Por-      reducing its pathogenicity over a brief period (4 weeks).
    phyromonas gengivalis and Fusobacterium nucleatum.               The difference in the significant improvements of the
                                                                     groups, even if only over a short time, documents that the




                                                                                    rn
    Discussion                                                       participation of the patient as well as caregivers/tutors in
    The analysis of the results of the examination of Oral Hy-       the educational phase is an effective strategy for the short-
    giene, Gingival Health State and Microbiological Analysis,       term.
    shows an overall improvement of the indices, compared            Our data confirms the hypothesis put forth in much of the




                                                                         te
    with the initial status, mostly at T1 in both examined groups.   literature to date, which is that the active interest in disa-
                                                                     bled patients’ lives from people close to them, can positi-
    STUDY GROUP (patients who participated in the educa-             vely affect their compliance. The fact that after 6 months
    tional phase of direct hygiene and oral health).
                                                                 In  the clinical indices in our study returned to the initial va-
    The results show that 4 weeks after the educational pha-         lues in both groups, demonstrates a decreasing motiva-
    se, the clinical and microbiological indices’ values de-         tion and compliance over time. In patients this decreased
    creased significantly in the Study Group patient. Conver-        motivation could be due to disability status itself and be-
    sely, after 6 months the overall clinical indices increased,     havioural problems. Likewise, the tutors may be impacted
                                                    ni
    although most microbiological values continued to de-            by time-factor. For example, over a longer period, they may
    crease.                                                          tend to underestimate the importance of oral prevention.
                                          io


    Table 3 - Marker bacteria.
                                       iz
                   Ed
 IC
C
©




    28                                                                                    Annali di Stomatologia 2011; II (3-4): 25-30
    Disabled patients and oral health in Rome, Italy: long-term evaluation of educational initiatives


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                                                                                                                                    li
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                                                                                                  az
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