An Index of Clinical Oral Disorder in Elders (CODE)

An Index of Clinical Oral Disorder in Elders (CODE) M I MacEntee and C C L Wyatt l \ k i i l l \ o l I H - n l i s l i v . L l n l w i s i l y ot" U n l i s l i C c i l u m l i i i i . 2 1 ' ! ' ) y V V s l i i o d k M i l l l . V ' ; i i K - n i i \ L i . Ii ('. VfiT' \ / } . CiMiiil.i Abstract Attempts to eonsttuct an index of otal health or disorder suitable for older adults have been limited in clinical scope or based on the judgement of vety few individuals. Consequently, we present here a multidimensional index of Clinical Oral Disorder in Elders (CODE) based on a breadth of clinical measures teley ant to elders. The data fortheindex are detived from a clinical examination of jaw function, dentures, mucosa. teeth, and periodontium. Weighting or ranking for each dist)rder within the context of an elderly petson was established as tiiild, moderate or sevete by experienced dental clinicians and dental hygienists. Subsequently, the index was constructed by transfortning the weights into a numerical value lor each clinical measure. Individual seores can relate to the heaviest weight identified during the examination or to the sum of the weights assigned throughout the examination, and the average score during a series ot examinations w ill reflect the clinical status of a particular population. Clinical applications in elderly residential-care populations indicate that the index can be constructed effieiently and with reasonable reliability. We suggest, therefore, that the CODE index is suitable for descriptive and comparative research by providing a clinical format for measuring (MLII di.sorder in disabled elders, and, when combined with a psychosocial index, it should be very comprehensive indicator of oral dysfunction in older adults Key words: dentistiy: examination; clinical index: geriatrics: long-term care. The enigma of oral health in long-term care (LTC) facilities is being addressed by expanding traditional dental serv ices through the co-operation of dentists, dental hygienists and hospital staff. Some regulatory bodies have imposed minimal standards of care on LTC facilities, although at present they are vague. For example, the regulations in British Columbia demand that the mouths of all new residents be examined soon after admission to a facility, but they do not specify who is to perform the examinations nor what followup is required'. Attempts have been made to establish general health indicators for several purposes-. On a very general level they offer an overall measure of a population's health, and a means of eomparing the health of different groups within the population. They allow estimates of need for health-related services ba.sed on measurements of functional and psychosocial impact, and, on a more individual level, they help to assess the outcome of tteatment in clinical trials. Indices of specific oral conditions, such as the DMF index'\ the T-Health indicator'. the periodontal index'\ the gingival index^ and the plaque index\ are available but rarely have they been used within the context of a comprehensive measurement of oral function. Cohen and Jago'' argued for the development of a sociodental indicator that would summarise the qualitative or psychosocial impact of oral health to reflect the overall well being of an individual. One of the first attempts to create a general measure of oral health for adults by Bulmanerfl/.'" assessed dental status, periodontal status and denture quality as part of an index with 17 ranks. A more elaborate approach by Nikias et o/." produeed 42 four-dimensional profiles of oral health from several clinical dimensions - missing teeth, cai ies, periodontal disease, and oral hygiene. Each profile was ranked from T to '9' b> 29 dental clinicians who agreed that missing teeth and periodi>ntal disease should weigh heavily on the final scote. They did not agree on how to rank situations with contrasting conditions, such as caries in the presence or absence of periodontal disease, nor did they addtess the aesthetie impaet Volume 16, No. 2 S(i M I M . u l nli' WN.IH ol missini! icelh. /\pplication ol the mean rank from their comhined iiulgeincnts olfeted i\ nutnerical score that served as a single scaled index of oral health. In an elfoil to rank conliasiing conditions, Maictis ('/<;/.''' identifietl v ai iablcs tliat inlluenced clinical picleiences l\v asking tientisis to rank successiv e pairs of clinical scenarios. The score or weight altached to each condition allowed the investigators to calculate an index for each individual patient, and the rankings revealed that pcriodonlal disease, missing teeth and caries are considered the major impediments lo oral heallh. Llnfortunately. the inyesligation did not consider jayv movements, denture status or mucosal iiealth as data lor the index. Recent trends in health care favour the measurement of functional status in clinical practice, particularly for older patients'^ using simple dichototnous or multiple-choice options'^"", although thev are not used widely in elinical practice possibly because they are linked rately to practical treattnents'-'. Following this trend, Kay ser-Jones el a/.'^ developed the 'Brief Oral Health Status Examination (BOHSE)' based on ten clinical variables - hygiene, dentition, and appearanee of the mucosa. Unfortunately, the clinical descriptors are y ague and the weighting of each y ariable yyas established arbitrarily. Nonetheless agreement betyveen and yvithin examiners was high, both for the total scores and for individual variables. Cunently. in industrialized countties, u substantial proportion of the elderly population is edentulous in at least one jaw"*-". Therefore, an index of oral disorder focused on institutionalised elders should give significance to assessments of denture quality, along with measures of mucosal health, caries, dental structure, and periodonlal disease. Recently, Burke and Wilson-' included all of the.se criteria in a composite index of oral health, with individual scores of zero or one for each condition and an overall score calculated by adding the individual scores. This index ofiers the widest scope of clinical v ariables appropriate for older adults but it offers no obvious weighting or ranking of the various measures. In summary, it is evident ihat others have given considerable thought to the construction of a comprehensive index of oral function. Yet, no existing index serves adequately as an overall measure of oral function appropriate to older populations either because the clinical base is limited or because the weighting attributed to each clinical measure is based on the opinions of very few clinicians. Furthennore, we believe that no one index will serve as a single measutv of oral health to reflect a comprehensive assessment of function and psychosocial impact". We do believe, nonetheless, that it is possible to construct a broad index that reflects oral di.sorder from a strictly functional perspeclive. This paper describes such an index focused on clinical oral disorders in elders (CODE) to serve as ihe clinical component of a comprehensive assessmenl of oral health in old age. Firstly, we identify the clinical criteria for measuring the specific functions of older mouths. Secondly, within the context of long-term care, we attribute a weight to each criterion from the judgments of dentists and dental hygienists. And, finally, we deseribe the index based on the weighted criteria. Rationale for .selecting tbe clinical components The selection of clinical components depends largely on the purpose of the indicator-, and on our current understanding ofthe cause and effects of the disorders. The index that we are describing is based on clinical measures of 27 disorders covering five major areas: jaw movement; dentures; mucosal health; teeth and periodontium. The validity of each measure has evolved largely from the consensus of experts rather then from experiment; nevertheless the consensus offers a practical basis for decisions in clinical dental practice. We will revieyv the evidence available on the measures not as a refiection of seriousness to elders but as they are encountered during the comprehensive otal examination. Mandibular and occlusal dysfunction (Figure 1) Although the prevalence of mandibular and occlusal dysfunction in old age is unusual, when it occurs it can be troublesome. We include an Figure 1. Components ofthe index relating to jaw function .Jaw Function Components Restrieted Opening: < 30mm between Ineisors; or < 45mm between residual ridues at mid-line 2 Opening Deviation: more than 10mm from the mid-line on opening the mouth to at least 20mm 2 TMJ or jaw muscle pain 2 Oeclusal Attrition: > two-thirds of > half the dentition I TMJ crepitation 1 Less than two opposing molars or premolars bilaterally 2 Acceptable: 0 Gerodontology (Jcrodonlokiyv Association "Code" Seore Highest Score A An index oCCIinKiil Onil DiMirikr in likkrsKoiii > 87 as.scssment of jaw runclion al Ihe Dutsct of the examination because of the need for external (faeial) and internal (oral) assessment. il opening An average opening 0150 millimetres between the upper and lower central incisors in healthy adults is accepted by some as normal on the assumption that less than 40mm is abnormal"-'-^ with 3039mm signifying slight, and less than 30mm severe, impairment of jaw function-'. Yet there is no empirical evidence that older individuals are impaired or even inconvenienced when restricted to 30mm of opening"-\ In our experience, a separation of al least 30mm between the anterior teeth, or 45mm between the crest of the residual ridges anteriorly in an edentulous mouth, is a more reasonable limit of normal temporomandibular joint (TMJ) function in elders. Opening deviation A lateral deviation of the mandible greater than 2mm when opening the mouth has been designated as abnormal-""^", although about one in ten individuals deviate without concern by at least 5mm from the mid-line when opening the mouth'^ Moreover, restricted jaw movements in denturewearers can stem from attempts to control unstable dentures rather than from a disorder of the joints or muscles'". As a practical limit of normality, we selected a lateral deviation of 10mm from the midline when opening the mouth to 2 centimetres. TMJ or jaw muscle pain Although responses to palpation should be interpreted cautiously, pain in the TMJ elicited by applying moderate finger pressure to the lateral (preauricular) and posterior (intrameatal) aspects of the joint, and palpable tenderness of the masticatory muscles, probably indicates inflammation-\ Popping and clicking noises from older joints rarely cause complaints unless accompanied by loud crepitation''". Therefore designations of TMJ disorder should be limited to manifestations of pain and crepitation. Occlusal attrition A four-part graded scale has been suggested (originally by Broca in 1979) for assessing dental wear or abrasion with the most severe condition described as the 'crown worn down to the collum dentis'". Smith and Knight'^ suggest that occlusal wear is a problem if more than a third of the enamel is lost, if dentine is exposed on incisors with a negative contour, or if there is a 2mm cervical defect. However, attrition or abrasion of the dentition generally, or localised abrasion along the gingival margins of teeth, rarely disturb older adults'', but it can be upsetting il the tcclh arc redueed to the point of excessive sensitivity or if facial appearance is disturbed. We suggest lhat occlusal wear in older mouths warrants attention only when more than two-thirds of the tooth structure is missing from more than half of the remaining dentition. Masticatorv ftinctinn Despite the loss of efficiency^'', adequate function is possible with an incomplete dentition providing there are about 20 teeth and the anterior teeth are intact"-'*'. We have selected bilateral contact between two opposing posterior teeth as the cutoff for a functional natural or artificial dentition. Dentures (Figures 2a and 2b) Recommendations from the World Health Organisation suggest that a new denture is needed when the remaining dentition is "incomplete", or when the denture is "unsatisfactory", however neither term is defined-"*""'. Others offer advice for appraising the stability and retention of dentures, and for measuring their impact on appearance, chewing capacity, speech and the underlying mucosa^'"", but without exception, the criteria are difficult to apply and interpret^'*^". There is mounting evidence that uncomplicated diehotomous (satisfactory/ unsatisfactory) scales offer the most reliable and praetieal measures of denture quality'"''\ Therefore, we base our evaluation of dentures on diehotomous measures relating to the use, stability, retention, strueture and Figure 2a. Components of the index relating to a maxillary removable prosthesis Maxillary Denture Code • " Score Components Use: not worn or missing when w denture can be managed 2 Quality (if worn) Stability: dislodged witli light finger to a premolar 2 Retention: dislodged or loose when the lips are licked with the mouth open approximately 15mm 2 Structure: missing parts, tractures, visihlc porosity or other structural delects 2 Hygiene: calculus or visible plaque >5(Kf of denture base 2 No Problems 0 Highest Sicrc Bl Volume 16, No. 2 88 M I M.KI .iM.ICl'l \\\;ili 2b. I'ompuncnls DI'IIK" IIHIC\ Id ;i m>inilihulai rcinuN ahli' pmsilk'sis Mundilniliir Dcndirc Code" .S LCI r e not worn o\ niissmi; wlu-n can StabiliiN: ilixlodgcd with liylil riiiiicr p i v s s u i c lo a pivniolar 2 RctciUion: dislodged oi loose wlien ihe lip.s are ikkeJ wilh ihe mouth open appio\iiiiali.'l\ 15nim 2 Slructure; niissm;: parls. rracliiios. poiosiiy. or other struciural delects 2 Hsgiene: calculus or \ isible plaque >SO"r of the denture hase 2 No Prohlems: 0 Hifihesl Si-iuv B2 Mucosa (Figure 3) Detailed descriptions of the mucosal disorders encountered in older mouths are available'", along with a systematic method of examining the mouth'. Usually the lesions are fed or white patches, ulcers, fistulas, abnormal lumps or swellings. And so, rather than outline the system for examining the mucosa^"^, we list the most frequently encountered disorders and generic manifestations in older populations""". Salivary Figure 3. Components of the index relating to mueosal disorders Mucosal Disorders Code • ' Seore Components Extreme alveolar atrophy (<lmm ol attached mucosa facially or lingually from the crest ol the residual ridge along at least 2cm ol the alveolus disorders are difficult to identify and symptoms cotielate poorly with recorded How rates unless thcte is very obvious xerostomia. Consequently, we focus the examination on conditions, such as lose denture, caries, gingivitis and stomatitis, which reflect disturbances of salivary glands when ptesent. Teeth (Figure 4) Missing teeth or tooth structure Decisions on the replacement of teeth or tooth structure rest largely on the choice of adhesive tnaterials with or without oral implants. We distinguish between missing anterior teeth and missing posterior teeth because adequate function is possible, as mentioned above", with a partial dentition providing the anterior teeth are intact. Furthermore, the adequacy of a fixed"' or a lemovable"- pontic, as with the natural tooth it replaces, can be evaluated for structural integrity, cleanliness and appearance. Figure 4. Components of the index relating to caries and tooth structure Status of Caries and Tooth Structure 'Code" Seore Components Tooth structure missing posterior (non-aesthetic) tooth missing anterior (aesthetic) tooth adequate fixed pontic adequate pontic on a removable partial denture inadequate pontic intact tooth or a tooth with an adequate restoration 0 fractured tooth or restoration 2 Caries not obviously involving the pulp obviously invoh ing the pulp Ridge fibrnsis (>2mm nmbility along >=2eni (4 the residual ridge) .Angular cheilitis TfHith Slructure Stomatitis - generalised or papillomatous (> 1 sq cm): 18 17 16 15 14 1? 12 II 2 3 21 23 24 25 26 27 28 Canes Stomatitis - localised 4X 47 46 45 44 43 42 41 Demure induced hyperplasui (epulis) 31 32 33 34 35 36 37 38 Tooth itructure .al pathoses: glossitis white patch pigmented patch ulcers abnormal lump sinus or fistula 3 3 3 3 3 3 Other urgent oral mucosal concerns 3 None ol the above 0 Canes If the highest score is ' I" and it is recorded on greater than 5iV-'r ofthe teeth present enter '2" as the highest CODE' score. Highest Score D Hii'he\i SI ore C Gerodontology © T h e (jcTixJiinloloyy AssntiutKin \'>')'i An index ul Clinical Oral Dismdcr in l.klcrsK'ODI) Criteria lor appraising the structural integrity of teeth or dental restorations are available for measuring surface texture and colour along with the structural integrity of a testoration'''"', yet, their ability to predict the failure of a tooth or testotation is unknown''\ We have adopted a simpler dichotomous appraisal based on the presetice or absetice of a visible fracture in the tooth or testotation'*. complicated Ireatment*'. We oiler two additional catcjiories lo the CPITN, one to lecord pockets with purulent discharge that may pose a risk of aspiration pneuttionia"', and the other lo identify leeth that are depressible vertically and comprotnising function. Figure 5. Components ol the index relating to gingival health and periodontium. Gingival Health and Peridontium Caries A change of sutface colour and hardness serves to help detect caries on the crowns of young teeth'^*'". however colour is a weak predictor of infection in older teeth"\ and hardness of root surfaces can vary quite substantially without infection''"™. Moreover, root lesions are accompanied only rarely by pain", and the choice of a sharp or blunt explorer to explore the dental surface can influence the diagnosis'-^''. Despite these complications, but recognizing that early decalcification of tooth structute can be remineralized, we adopted the conservative view that carious lesions on coronal surfaces of teeth are opaque and soft, whilst infections on root surfaces are yellow, light brown or black and soft, tacky or leathery to probing"-^''. We suggest also that the presence or absence of an obvious pulpal exposure warrants attention because of treatment implications. Periodontium (Figure 5) Gingival bleeding, loss of periodontal attachment and deposits of calculus provide clinical evidence of gingival and periodontal disorders^". Gingivitis Localised or generalised Inflammation of the gingiva bleeds on probing with a blunt Periodontitis The loss of periodontal support confirms the activity of periodontal disease'", although this measure alone is an unreliable predictor of tooth loss*". Explorers and probes are available for measuring the loss of periodontal attachment from the cemento-enamel junction to the free gingival margin, and from the gingival margin to the base of the periodontal pocket*'. Beck*- has defined serious periodontal disease as "four or more [dental] sites with loss of attachment of 5 or more millimetres and one or more of those sites [with] a pocket depth of 4 or more millimetres". The Community Periodontal Index of Treatment Needs (CPITN) identifies treatment needs from a pocket depth of 5.5mm as the marker between simple and Components C'ddc' Score Missing tooth not to be replaced 0 No gingival bleeding and < 5.5mm pocket from free gingival margin Gingival bleeding and < 5.5mm pocket 0 (localised gingivitis) I Caleulus 1 Poeket depth > 5.5tnm without purulent discharge 2 Pocket depth >5.5mm with purulent discharge 3 Vertically depressible (elass III mobility) 3 "'8 18 17 16 15 14 13 12 11 ">1 4K 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 "•I •'6 ••7 If the highest score is ' 1" and it is recorded on >5()'7r of the teeth present enter '2" as the highest 'CODE" score. Highest Seore E Weighting speciflc disorders Thirty-three general dentists or prosthodontists and 11 dental hygienists, all with at least five years of clinical experience, were approached individually and asked to assign a weight of mild, moderate or severe to each of the 11 disorders. The dental hygienists had extensive experience with residents of LTC facilities whilst the dentists and prosthodontists were very fatniliar with oral disorders in older patients. The clinicians were presented the list of conditions with instructions not to confer with one another. They were asked to weight each condition separately, without contrasting it to other conditions and within the single context of a disabled 75 year-old individual living in a LTC faeility. We seleeted three weights because variability is tninimized with fewer categoties'^^, and we transformed the weighting frotn categorical to numerical values (mild = 1; moderate = 2; severe = 3) so that a mean score could be calculated for each disorder. The weights assigned by the dentists and the dental hygienists Volume 16, No. 2 M I M.u I ,iiul ( r I \ S \ , i M CoirsLsU'iicy of weightings simiLii, \\lin.h allow od us lomlopl Ihc weiglil K-il lo each drsordcr by the nuijotily of the clinKiaiis ( lahk- I). .\ low dciitisis did not woight o\or> tlisordot", hut iho small tnimhcr ol missing data would not lia\o iiilluoiKod tho niajority sooro. T a h I c 1. T h e c l i n i c a l s e \ e i it\ * a s s p j i i e i l b \ Tho consisionoy of ihe weighting assigned by ten ol Ihe dentists was measured by comparing the weights assigned at baseline with those assigned to the same olinical soenario one month later. The dcntisis and 11 dental hygienists to vurinus oral disorders in disabled elders Or.il 1 Dentists 2 C .Hies involving the pulp 1 II \erticallv mobile (depivssible) tooth vv ith ( 5 5mm periodontal pocket .S Glossitis, nnuosal while patch, pigmented patch, or ulcer, abnormal lumps cal S e s e i i U Hygienists Dentists & Hygienists 2 3 Mean 1 2 3 21 4 7 1 15 28 2.fi 10 17 6 4 5 16 21 2.4 2 ? 6 3 -> 11 31 2.7 .Sums or fistula "> g 26 -)-> 4 7 13 29 2.6 Hxtreme alveolar atropin (<l[nm attached mucosa laciallv or lingualh from the crest ol the ridge along at least 2mm ot the alveolus) 4 13 16 3 7 1 7 20 17 7T Missing, unused, or structurallv defective denture for anterior tooth II 20 3 4 4 14 24 6 1.8 3 12 22 10 2 14 25 5 1.8 10 2X 6 1.9 3 1 17 7 3 5 11 17 5 3 8 L nstablo or unh> gienic denture 9 20 4 8 Loose upper denture* ' s 15 S 1 -) 7 10 22 10 2 Loose lower denture 12 14 7 5 6 17 20 7 1.8 Residual ridge fibrosis (> 2mm mobility along at least 2cm ot the residual ridge)** 12 15 4 3 7 15 4 1.7 Angular cheilitis 11 19 3 4 6 1 14 20 8 1.9 Generalized or papillomatous stomatitis 6 IX 9 1 6 3 8 23 13 2.1 Localized stomatitis 9 22 2 6 3 1 15 21 7 1.8 Denture induced hyperplasia 12 17 4 4 6 1 21 16 7 1.7 Damaged teeth or restorations with adequate dentinal support for a restoration 14 17 -) 1 9 1 16 23 5 1.8 Anterior tooth with inadequate dentinal support for a restoration 10 18 5 1 8 -> 14 -)-) 6 1.8 Posterior tooth v\ ith inadequate dentinal support lor a restoration or inadequate posterior pontic II 19 3 10 1 17 23 4 1.7 Canes not involving the pulp 15 18 20 21 3 1.6 Periodontal pocket >5.5mm 3 26 4 Generalized gingival bleeding 8 IX 7 Less than two opposing posterior teeth bilaterally 11 1(1 6 6 5 Missiny anterior natural tooth 12 18 3 5 3 Occlusal attrition 20 11 2 9 1 IMJ crepitation 17 22 12 4 6 5 fi 4 Restricted opening or dev lation TMJ or muscle pain Localized gingival bleeding ' | = M i l J . 2=MiHli..rutc; 3 = S L V c r c 11 M i s s i n g r c s i m i i s c s Iroiii d c n l i s i s Ass(icijn<in 1W9 T 9 3 5 3 11 26 6 1.9 10 1 16 21 7 1.8 17 21 6 1.8 3 23 16 3 1.5 1 26 14 3 1.5 20 18 4 1.6 26 14 3 1.5 1 SD=Standard ncvialion Gerodontology ©The ~i An indix of riinicul Oral Dlsonk-i in l-.ldcrsfrorx') '^ dentists rendered the same weight to 23 (85%) of the 27 disorders. On the five occasions when they changed the weight, it was by no more than one category. We conclude, therefore, that the weighting reflects with reasonable reliability ihe opinions of experienced clinicians. Format and length of the examination The format of the examination has been designed foreftlcicney (Figures 1-5). Forexample, cxtrat)ral observations are made before intraoral observations, and a removable denture is examined in funetion before it is removed to evaluate the supporting residual ridge. The time required in a LTC facility to examine elders with and without natural teeth was measured by three dentists exposed to at least one hour of instruction on the fonnat and criteria of the examination. On average, they required nine minutes (range 5-14mins) to examine each of 20 dentulous (minimum 14 natural teeth) elders, and four minutes (range 3-5mins) to examine each of ten denture-wearers. Calculating the index The overall 'CODE' score for an individual ean coiTespond to the highest (1, 2 or 3) score reeorded anywhere during the examination if the objective is a three-part eategorieal distinction of treatment needs, or it ean correspond to a cumulative score for a more numerical discrimination between indi\iduals. Similarly, nominal groupings and mean scores can be determined for populations. Intra-examiner and inter-examiner agreements One dentist examined ten elders on two occasions at least one week apart. The repeat examinations produced the same overall CODE score and agreement ranging from 93-99% on individual components of the examination. To measure the agreement between examiners, two dentists examined independently on the same day seven elders in LTC. They disagreed once on the overall score indicating an 86% agreement, and they differed by only 0.15 points for the mean population score. Disagreement occurred in assessing the retention and stability of a complete upper denture for one individual, and in assessing the structure (i.e. oeclusal abrasion) of both dentures in another. They disagreed also on whether a periodontal poeket in one subjeet was greater or lesser than 5.5mm - a disagreement that would change the overall CODE score. In all, the intra-examiner and inter-examiner agreements seem acceptable although additional measurements of agreement would be useful to define more clearly the limits of the index. Discussion The clinicians weighting the components of the index, in keeping with the clinical judgement of others", placed highest significance on inflammation and other manifestations of oral infection. Nikias el <il.'' suggested that disagreements in clinical weightings occur when the clinical profile has contrasting conditions, a problem we did not encounter because the clinicians were asked to rank each condition independently. To our surprise, the dentists and dental hygienists alike gave a lighter weight to components such as missing anterior teeth or dentures that we felt would have a large social impact. This might be a reflection of the conflict reported by others*^ between the eoneerns of dentists and those of their older patients, despite the experienee of the elinieians. It also highlights the need for another perspective of oral disorder one that represents the elder's concerns-- and their propensity for treatment-". The two perspectives in eombination should offer a comprehensive assessment of oral health-related needs and a useful indicator of treatment benefits in elderly populations. If the purpose of the CODE seore is to compare the cumulative score or the distribution of nominal ranks for different groups, then the examiner agreement we recorded is very acceptable. This is consistent with previous tests of agreement using the same measures in a similar clinical environment'*\ However, the numbers of repeat examinations were small and we believe that additional tests are required to establish more securely the consistency or reliability of the index. The clinical measures have been incorporated within a computer program that ehecks the consistency and appropriateness of the recording process. The scoring system for the CODE index is part of the program also but further tests in the field are needed to determine the practical contribution offered by the eleetronie management of data to the efficieney and reliability of the index. We focused the index on disorder rather than illness or health because usually most oral diseases are visible and reasonably amenable to measurement. In contrast, illness and health are subject to a wide spectrum of psychosocial factors that are notoriously unreliable to psychometrie measurement" ^". Interest in diagnostic markers has been direeted predominantly at the prediction of caries""'*', mucosal diseases"-, loss of periodontal attachment and of teeth''\ although the extent to which any particular marker will predict the presence (sensitivity) or absence (specificity) of a Volume 16. No. 2 I' M l -i' u n i t C " l ' t , \ \ \ . i l l disorder is \ cry unccilam"'. Yet, there is a practical need for an index that is easy to use and biologically lustiluiblc in ihe context ol older adults with severe functional disorders. The demand for oral healthcare in I rC facilities continues lo grow but with increasing instance on an 'c\ iilcncc based' service. Undoubtedly, the pinsical and mental health of the residents will influence their dental needs. Therefore, decisions ti> render any invasive treatment should be preceded at very least by a screening e|uestionnaiic"'. and by direct consultation with others who can identify indi\ iduals at particular risk"\ We recognise also the need to consider the psychosocial impact of oral disorder from the perspective of both the examiners and their subjects"""\ Other indices of oral health focus on the psychosocial measures pertaining to quality of life but they are limited by the exclusion of clinical status"\ We believe that the CODE index combined with a psychosocial index will offer a \cry eomprehensi\e indicator of oral dysfunction in older adults. Our approach with the 'CODE" Index has been to use clinical measures that are relatively unambiguous and closely associated with treatments for specific disorders in older adults. The index offers a practical means of classifying oral health that is based on three lexels of clinical severity validated by the consensus of experieneed dentists and dental hygienists. Since there is no 'gold standard' of oral health for elders in longterm care, or indeed in any other setting, it is quite likely that application of the clinical measures adopted b\ us will need minor adjustments to meet the needs of particular populations. This raises the question, of course, on the feasibility of any index to meet the needs of all clinical situations. Ne\ ertheless, there does appear to be a practical need in comparati\ e and process research for some overall measure of oral health based on widely accepted elinical criteria. At very least, our index offers a model of scoring oral health that may help others who wish to provide a standard format lor clinical studies of oral disorder in old age. More ambitiously, we hope, that we have produced a tool that will appeal to clinical researchers whoeolleet data on oral disorders, and who want to predict the need for treatment or to monitor the impact of care in elderly populations. References I Government of British Columbia Order in Cduncil #1105. Victoria, B.C.: Appended and otdcred October 1st, 1997 to amend Section 9 of the Adult Care Legislation, 1997. 2. Mootz M. Health indicators. Soc Sci Med 1986:22: 255-263. 3. Klein H. Palmer C E, Knutson J W. Studies on dental caries: dental status and dental needs of elementary school children. Public Health Rep 1938; 53: 751-765. 4 Knutson J W. Klein H. Palmer CE. Dental needs of grade-school children in Hagerstown, Maryland. 7/4/?; Dent As.soc 1940; 27: 579-588. 5. Sheiham A, Maizels J, Maizels A. New composite indicators of dental health. Community DentHlth 1987; 4: 407-414. 6. Russell A L. 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Med Care, 1995; (NS57-NS77, Suppl), p. 33. Address for correspondence: M 1 MacEntee Faeuli) of Dentistry, University of British Columbia, 2199 Wesbrook Mall, Vancouver. B.C. V6T 1Z3 Tel: (001)604 822 3564 Fax: (001)604 822 3567 e-mail: [email protected] Gerodontology <'j The (i(.Tinliinli>l(iLiv A s M M . i j l i i i n I W^>