Oral health in the older patient

Oral health is an important indicator of our overall health. Not only is the mouth vital for eating, drinking, taste, breathing, verbal and non-verbal communication, saliva also has antibacterial properties and is part of the body’s defence against infection. Healthy teeth are essential for effective chewing and swallowing and therefore for good nutrition.

Our teeth are on show to others when we smile, and for many of us it is important for confidence and self-esteem to feel that our teeth look acceptable. After years of eating, drinking, chewing and brushing, some depreciation of the teeth with age is natural.

The facial muscles become soft and fragile and the stretching capacity of the gums is lost. Teeth become weak and fragile and the receding gums make the teeth susceptible to periodontal diseases. The elderly are often unable to take proper care of their teeth due to overall weakness or problems like arthritis, making it difficult to stand for long in front of the sink and brush/floss thoroughly. Bacteria in the oral cavity attach to the tooth pellicle to form a sticky, colourless ‘plaque’ biofilm on teeth. The plaque that is not removed by brushing and flossing harden and form ‘calculus’. Calculus is difficult to remove by simple brushing and requires professional cleaning by a dentist.

Sometimes older people are reluctant or unable to tell their dentist their problems. They might even overlook dental problems because of other more demanding health problems. In such cases it is essential for family members to watch out for symptoms. Weak or loss of teeth also means difficulty in eating leading to lack of nutrition. Untreated dental problems can lead to certain diseases especially in the older people. The reverse is also true due to the impaired immune system of elderly. Systemic diseases like diabetes, leukaemia, cancer, heart and kidney diseases are all interlinked with dental problems.

Epidemiology of oral health

There are 10.8 million people aged 65 or over in the UK.¹ The proportion of people aged over 65 years will rise from 17.2% currently to 22.4% in 2032.¹ It is projected that by 2040, about 14% of the global population, or almost 1.3 billion people, will be aged 65 years or older.² Such a demographic change poses pressing concerns for healthcare as an increasingly geriatric population brings with it a host of health issues including chronic diseases. Declining oral health also tends to be common amongst the elderly and this is an issue which warrants attention.

Rates of edentulousness range from 6% to 78% worldwide,3 but in industrialised countries an ever growing number of elderly retain an increasing number of their teeth. For functioning dentition, a minimum of 20 teeth has been suggested since the 1980s. It has been adopted as a goal by the World Health Organization⁴ that more than 50% of those aged 65 and older possess at least 20 functioning teeth. Such a goal has been achieved in the UK.5 Of the dentate 65-74-year-olds in the population study in the UK, 74% report having seen a dentist within one year.⁵

In a survey by Age Concern, just over half of the respondents said that they were registered with a NHS dentist. This declined further with age and varied considerably between regions (Primary Concerns, Age Concern Policy Unit, 2008).⁶

In 2009, 23% of people aged over 65 years did not have any natural teeth⁷ (Adult Dental Health Survey 2009-First Release. NHS Information Centre, 2010).  During the 24 months leading up to 31 March 2008, only 53.3% of the total population of England were seen by an NHS dentist  (Later Life in the UK Factsheet August 2013).⁸

Age-related oral changes

As a person grows old, teeth show signs of wear and tear, gums recede, soft moist oral mucous membrane sometimes looks more rough, dry and at times fibrous. Root pulp becomes smaller with age and hence unable to provide sufficient support to the nerves and blood vessels, making the teeth fragile. Teeth also become brittle due to insufficient nutrition. Brittle teeth break away easily. With ageing, the appearance and structure of teeth tend to change. Yellowing or darkening of the teeth is caused by changes in the thickness and composition of the underlying dentin and its covering, the enamel. Abrasion and attrition also contribute to changes in tooth appearance.

The number of blood vessels entering a tooth and the enamel decrease with age, leading to reduced sensitivity. With reduced sensitivity to environmental stimuli, the response to caries (decay) or trauma may decrease. The cementum (ie. the substance covering the root surface) gradually thickens, with the total width almost tripling between 10 and 75 years of age. Because the cementum is highly organic, it is less resistant to environmental agents, such as sugar, acids from soft drinks, and tobacco, which has a drying effect.

Age-related changes in the oral mucosa and dietary or hormonal deficiencies lead to diminished keratinization, dryness, and thinning of the epithelial structures. Additionally, the width and fibre content of the periodontal ligament, which is a part of the attachment apparatus of the periodontium, decreases with ageing.

Gingival recession is another common condition in older persons, but is not considered a normal age-dependent oral change. Gingival recession exposes the cementum, predisposing to root caries.

The salivary glands produce less saliva with older age which causes dry mouth and difficulty in chewing, often as a result of medication.

Special oral issues in old age

Common chronic diseases of the elderly such as diabetes, cardiovascular, liver diseases, and gastrointestinal diseases have their effect on oral cavity. Many elderly patients are under treatment for various conditions such as cardiovascular diseases, blood pressure, depression, gastric disorders etc. Several medications which they receive for these conditions have side effects on teeth, gums and other tissues in the mouth (eg. dryness of mouth as a result of antidepressant drugs).

Old age may also bring about changes in drug metabolism that may have its oral side effects such as changes in taste, oral ulcerations, gingival bleeding etc. Psychiatric elderly patients have a higher prevalence of edentulism than in the general population of the respective age group, relatively poor oral hygiene and a higher incidence of dental caries.^10,11

Older people may have difficulty managing their own oral care due to problems with dexterity, as well as being unable to tell their carer when they are in pain. Additionally, denture wearers are at increased risk of chronic atrophic candidosis (denture stomatitis).

Impairment of memory, anxiety behaviour, sleep disturbance, depression, and disorientation are a few conditions which need consideration when dental treatment is planned.

Patients with chronic, disabling medical conditions (eg. arthritis, neurologic impairment) may benefit from oral health aids, such as electric toothbrushes, manual toothbrushes with wide-handle grips, and floss-holding devices.

Older people in residential care are at considerable risk of oral infection, with infection identified in 80% of one study population.¹²

Common oral diseases affecting older people

An increasing number of older persons have some or all of their teeth intact because of improvements in oral health care, such as community water fluoridation, advanced dental technology, and better oral hygiene. This increasing elderly population is at risk of chronic diseases of the mouth, including dental infections (eg. caries, periodontitis), tooth loss, benign mucosal lesions, and oral cancer.

Dental caries

Dental caries can occur at any age. However, because of gingival recession and periodontitis, older persons are at higher risk of developing root caries.13 The incidence of root caries in patients older than 60 years is twice that of 30 year olds, 64% of persons older than 80 years have root caries, and up to 96% have coronal caries (above the gum).¹³

Despite the general trend of decline in the occurrence of caries among adults in industrialised countries, caries is still a public health concern, particularly in less developed countries and in underprivileged groups, such as the elderly. Dental caries is a major threat for tooth loss in the elderly, accounting for up to 60% of extractions.¹³

Risk factors for coronal and root caries lead to increased exposure to cariogenic bacteria, such as Streptococcus mutans, Lactobacillus, and Actinomyces.¹⁴ Caries is a multifactorial disease with important risk factors in the elderly being fermentable carbohydrates, plaque, especially in the presence of restorations and prosthesis, decreased dexterity and saliva secretion, and the use of medications.¹⁵

Other oral conditions

Because older patients are more likely to visit a physician than a dentist, primary care physicians have an opportunity to improve oral health in this population by assessing oral health risk, identifying and treating common oral conditions, and referring patients to a dentist, if needed.

Geriatric dentistry or gerodontics is the delivery of dental care to older adults or the elderly. It involves the diagnosis, prevention and treatment of problems associated with normal ageing and age-related oral diseases. Geriatric dentistry is a science that is a multidisciplinary and multidimensional approach to the management of the oral health problems of the elderly.

Oral health assessment

An abbreviated history checklist that patients may fill out in the physician’s office or at home can help physicians assess oral health risk. On examination in a healthy mouth, oral mucosa and the tongue should be pink and moist, with smooth and moist lips and clean teeth or well-fitted dentures. Several assessment tools have been proposed but evidence is limited on their effect.¹⁶

Nutritional assessment occurs during most admission procedures and many hospitals in the UK use the Malnutrition Universal Screening Tool (MUST). This tool, designed by the British Association for Parenteral and Enteral Nutrition, includes a swallowing assessment for ability to maintain oral intake.¹⁷ The ability to assess swallowing is a required outcome in the essential nursing skills cluster for nutrition¹⁸ and linking the oral assessment to this would provide a holistic model of care.

There are also screening tools that can be administered by non-dental professionals including in a residential care facility. A simple, valid, and reliable dental screening tool is The Oral Health Assessment Tool.¹⁹ The only materials needed to perform the assessment are a penlight, gloves, and a tongue blade. Eight oral health categories are marked as healthy, changed, or unhealthy to help determine the next steps in the patient’s care. Using this tool, non-dental healthcare professionals such as doctors and nurses can recognise and identify less than optimum states of oral health so that patients can be referred for necessary follow-up with the dental surgeon.

Greater attention on the part of health professionals to the oral health status of elderly people may reduce the prevalence of oral cancer in the older adult population. Early detection and referral of oral cancer are critical steps that affect the success of treatment and survival rates. This is a specific concern in most developing countries where access to health services, primary health facilities, and health personnel are limited.

Physicians and other health professionals see their elderly patients more frequently than do oral health professionals²⁰ suggesting that other health personnel could potentially provide the elderly subjects with relevant information to support them in oral self-care.

Link between oral health and general health

Oral health is an integral and important part of one’s overall health but it is often neglected due to prevailing misconceptions which include a general apathy towards oral health since many conditions affecting the oral cavity are non-life threatening. Therefore, while elderly  are willing to attend annual health checks for their blood pressure, blood sugar, height and weight; the same interest for dental check-ups is generally lacking.

One of the advances of the 21st century has been the recognition of oral health as an essential and integral part of systemic health. Increasing evidence has linked oral health and general health, suggesting a relationship between periodontal disease and diabetes, cardiovascular disease, pneumonia, rheumatologic diseases, and wound healing.²¹ The close association between periodontal disease and diabetes is well documented in the review of literature.²² Increasingly, evidence of a close association between periodontal disease and cardiovascular disease is also emerging.²³

Inadequate oral care can be detrimental to social and emotional well-being and adversely affect interaction with others.²⁴

Poor oral health is often associated with lower economic status; lack of dental insurance; being homebound or institutionalised; and the presence of physical disabilities that limit good oral hygiene, such as arthritis and neurologic impairment.²⁵

Conclusion

As we continue to live longer, the need for proper oral care is vital to maintain natural teeth and enhance the quality of life. Conditions such as toothaches, tooth loss and dry mouth happen naturally with age but most of these conditions result from diseases of the teeth such as periodontal disease and dental caries or side effects of medications. We can all keep our teeth longer by maintaining good oral health. Oral health is part and parcel of an individual’s general health and wellbeing. Oral health status in the elderly reflects cumulative outcomes of oral health behaviour, diseases and their treatments during one’s life span.

Nowadays it is increasingly common that the elderly retain most of their teeth presenting a challenge for professions to maintain dentitions for a whole lifetime. The general medical practitioner can identify early signs of oral diseases and alert their elderly patients to seek further follow-up with their dental practitioners. Nurses can recognise and identify suboptimal states of oral health and refer the patient to a dental surgeon or oral health therapist for further management.  Early referral to a dental surgeon or an oral health therapist (eg. dental hygienist; dental therapist) can enhance the patient’s overall quality of life.

---

Dr Matthew West, GP

Conflict of interest: none declared

---

References

1.  Mid-2012 Population Estimates UK Office for National Statistics, 2013 http://www.ons.gov.uk/ons/rel/pop-estimate/population-estimates-for-uk–england-and-wales–scotland-and-northern-ireland/mid-2011-and-mid-2012/stb—mid-2011—mid-2012-uk-population-estimates.html
2. http://transgenerational.org/aging/demographics.htm
3. Petersen PE, Bourgeois D, Ogawa H, Estupinan-Day S, Ndiaye C. The global burden of oral disease and risks to oral health. Bulletin of the World Health Organization 2005; 83: 661-669
4. WHO 1982. Federation Dentaire Internationale. Global goals for oral health by the year 2000. Int Dent J 1982; 32: 74-77.
5. Kelly M, Steele J, Nuttall N, Bradnock G, Morris J, Nunn J, Pine C, Pitts N, Treasure E, White D. Adult Dental Health Survey. Oral Health in the United Kingdom 1998. Office for National Statistics, pp 13-400. London: The Stationary Office, 2000.
6. http://www.ageuk.org.uk/documents/en-gb/for-professionals/research/primary%20concerns%20%282008%29_pro.pdf?dtrk=true
7. http://www.dhsspsni.gov.uk/adultdentalhealthsurvey_2009_firstrelease.pdf
8. http://www.ageuk.org.uk/Documents/EN-GB/Factsheets/Later_Life_UK_factsheet.pdf?dtrk=true
9. Berg R, Morgenstern NE. Physiologic changes in the elderly. Dent Clin North Am. 1997;41(4):651-668.
10. Lewis S, Jagger RG, Treasure E. The oral health of psychiatric in-patients in South Wales. Spec Care Dent 2001;21:182-6.
11.  Hede B, Petersen PE. Self-assessment of dental health among Danish noninstitutionalized psychiatric patients. Spec Care Dent 1992;12:33-6.
12.  Nicol, R. Nicol,R.,Petrina,S.,McHugh,S.,Bagg,J. Effectiveness of health care worker training on the oral health of elderly residents of nursing homes. Community Dentistry and Oral Epidemiology;2005. 33: 115-124.
13. Saunders RH, Meyerowitz C. Dental caries in older adults. Dent Clin N Am 2005; 49: 293-308.
14.  Shay K. Root caries in the older patient: significance, prevention, and treatment. Dent Clin North Am. 1997; 41(4):763-793.
15. Curzon MEJ, Preston AJ. Risk groups: nursing bottle caries/Caries in the elderly. Caries Res 2004; 38 (Suppl 1): 24-33.
16. Cooley, C. Oral health: basic or essential care? Cancer Nursing Practice.2002; 1: 3, 33-39.
17. Elia, M. The ‘MUST’ Report. Nutritional Screening of Adults: A Multidisciplinary Responsibility. Development and Use of the €˜Malnutrition Universal Screening Tool’ (€˜MUST’) For Adults. 2003. Redditch: BAPEN
18. NMC . Essential Skills Clusters (ESCs) for Pre-Registration Nursing Programmes: Annexe 2, NMC Circular07/2007. London: NMC 2007.
19. Chalmers JM, King PL, Spencer AJ, Wright FAC, Carter KD. The Oral Health Assessment Tool €“ Validity and reliability. Australian Dental Journal. 2005;50:(3):191-199
20. SHARE 2005. Survey of Health, Aging and Retirement in Europe 2005. http://www.share-project.org.2005.
21. Rose LF, Steinberg BJ, Minsk L. The relationship between periodontal disease and systemic conditions. Compend Contin Educ Dent. 2000; 21(10A):870-877.
22. Bascones-Martinez A, Matesanz-Perez P, Escribano-Bermejo M, González-Moles MA, Bascones-Ilundain J, Meurman JH. Periodontal disease and diabetes-Review of the Literature. Med Oral Patol Oral Cir Bucal. 2011 Sep 1;16(6):722-9
23. Williams RC, Barnett AH, Claffey N, Davis M, Gadsby R, Kellett M, Lip GY, Thackray S. The potential impact of periodontal disease on general health: a consensus view. Curr Med Res Opin. 2008 Jun;24(6):1635-43. Epub 2008 Apr 30
24. Rawlins, C.A., Trueman, I.W. Effective mouth care for seriously ill patients. Professional Nurse. 2001; 16: 4, 1025-1028.
25. Saunders R, Friedman B. Oral health conditions of com-munity-dwelling cognitively intact elderly persons with disabilities. Gerodontology. 2007; 24(2):67-76.