Oral health is essential to general health and quality of life for older adults. Chronic disease increases the burden of oral disease, predisposing older adults to oral microbial infections, pain, altered taste, difficulty chewing and speaking, and dysphagia. Clinical research demonstrates the benefits of maintaining oral health and the deleterious consequences of oral neglect.
Weight loss and failure to thrive are common in patients with poor oral health. Concomitant psychosocial consequences undermine self-esteem, compromise social interaction, and contribute to chronic stress and depression.
Periodontal disease (gum disease) is the sixth leading complication of diabetes and threatens glycemic control. Poor glycemic control is associated with a 3-fold increase in the risk of periodontal disease. Treatment of periodontal disease results in a 10% to 20% improvement in glycemic control.
Xerostomia (dry mouth) seriously impairs oral function, promotes dental caries (tooth decay), and exacerbates periodontal disease. Decreased salivary flow is a side effect of 500+ medications, including tricyclic antidepressants, antihistamines, antihypertensives, and diuretics.
Oral cancer is the eighth most common cancer in men and is 7 times more likely to occur in older adults.
Aspiration pneumonia is the major reason for hospital admission from nursing homes and has a mortality rate of 20% to 50%. Effective daily oral hygiene lowers the incidence of aspiration pneumonia among patients in nursing facilities and hospitals.
By addressing oral health needs, health care professionals play a critical role in improving the health and quality of life of older adults. Clinicians should be familiar with normal and pathologic oral morphology. Clinicians have a positive impact by counseling patients on effective preventive measures, including regular dental visits.
Oral Disease & Access to Care
Although changes in oral health are not inevitable consequences of aging, profound, yet often asymptomatic, untreated oral disease is frequently present in older adults. Twenty-three percent of older adults have untreated dental caries, and 70% have periodontal disease. Almost a third of older adults are fully edentulous (missing all natural teeth). Seniors older than age 65 years average 19 remaining teeth. The World Health Organization recognizes that of the original 32 teeth, 20 constitute the minimum adequate functional dentition. Seventeen percent of older adults experience orofacial pain, including jaw joint, facial, oral sores, burning mouth, and toothache. Chronic orofacial pain can be associated with increased frailty, social withdrawal, decreased activities of daily living, and diminished quality of life.
Only about half of older adults have had a dental visit during the past year, with lower access to care for minority, impoverished, or institutionalized elders. Medicare and most state Medicaid programs do not cover preventive or restorative dental treatment for older adults. Dental insurance is typically not a retirement benefit. As a result, older adults pay a significant portion of their dental expenses out-of-pocket, limiting their treatment choices and ability to receive care.
Gingivitis, the earliest and most common form of periodontitis, is limited to the gingiva. It is associated with plaque, hormonal changes, or a foreign-body response. Gingivitis normally reverses with no lasting damage upon effective plaque removal. It often progresses to periodontitis, resulting in inflammatory destruction of periodontal ligament and bone attached to the tooth root.
Periodontal disease and associated pathogens have been linked with diabetes, peripheral vascular disease, cerebrovascular disease, and coronary vascular disease. Causation has not been established. However, inflammatory cytokines produced in periodontitis are implicated in atherogenesis. Periodontal disease can progress rapidly in those with impaired immune systems. Smoking and poor oral hygiene are the most common risk factors for periodontitis. Periodontal disease is marked by the loss of alveolar bone around teeth. Advanced periodontitis leads to increasing tooth mobility and loss. Treatment with oral antibiotics and chlorhexidine mouth rinse can slow progression, however, a dental referral for root surface debridement may be necessary.
Fifty-nine percent of those age 60–69 years and 72% of those age 70+ years have fewer than 20 remaining teeth. Having fewer than 20 teeth compromises masticatory function and nutritional status. It is associated with smoking, low socioeconomic status, low physical and social activity, frailty, living alone or in a nursing home, poor access to care, and higher mortality rates. Even with dentures, fewer than 20 teeth leads to decreased blood levels of vitamins and minerals; decreased consumption of vegetables, fruits and fiber; overprepared and overcooked foods; and increased caloric intake as a result of preferential consumption of fats and sugars.
Dental caries is an infection. Oral bacteria colonize exposed tooth surfaces, metabolize carbohydrates and release acids that demineralize tooth surfaces, potentially leading to a cavitated lesion. Twenty-three percent of older adults have untreated dental caries, a rate similar to children. Root caries is the major cause of tooth loss in older adults, and tooth loss is the most significant oral health-related negative variable of quality of life for older adults. Recurrent caries constitute new infection around existing fillings and crowns. Caries can destroy the structural integrity of a tooth before the patient experiences pain. Metastatic bacterial infections of dental origin have been reported in virtually every organ system. Those with active or recurrent dental caries benefit from fluoride varnish applications and high-fluoride toothpaste, available by prescription.
Restorative dentistry offers patients several tooth replacement options:
A complete denture replaces all the teeth in the maxilla and/or mandible.
A removable partial denture replaces some teeth and is connected by clasps to remaining natural teeth.
Fixed bridges replace 1 or more missing teeth and are connected by crowns to the adjacent teeth.
Dental implants are surgically placed into the jaw and can be used to support individual crowns, fixed bridges and removable dentures.
Properly made, well-fitting complete dentures restore only 10% to 15% of masticatory function. Patients with complete dentures commonly have difficulty eating and may be dissatisfied with their facial appearance. Over time, as the alveolar bone remodels, the ridges upon which the dentures rest resorb and change shape. Unless dentures are periodically relined, the vertical dimension of the lower face is lost and dentures can become ill fitting, impairing speech, compromising self-image, and further reducing masticatory function. Poorly fitting dentures can disrupt the normal flora and result in oral candidiasis infection. Angular cheilitis is a common consequence of the loss of vertical dimension.
Oral candidiasis is the most common fungal infection in humans, and is underdiagnosed among older adults. Up to 65% of denture-wearers experience oral candidiasis. Dentures that are worn for excessive periods of time with improper removal and cleaning can result in an overgrowth of fungus and cause burning sensation and irritation to the roof of the mouth, denture stomatitis or papillary hyperplasia (pebbly appearance).To reduce the likelihood of denture stomatitis, a candidiasis infection, and accelerated bone resorption, dentures should not be worn overnight. Individuals with dentures should be instructed to remove the denture for at least 8 hours daily to allow tissue bearing areas to heal and recover. To treat oral candidiasis, topical anti-fungal agents are applied to both the oral tissues and denture, typically for several weeks.
Oral cancer is the eighth most common cancer in men and is seven times more likely to occur in older adults. Squamous cell carcinoma comprises 96% of oral and pharyngeal malignancies. Age is the primary risk factor, along with the use of tobacco and alcohol. Both leukoplakia (white patch) and erythroplakia (red patch) persisting for more than 2 weeks, particularly those that progress to raised plaques of mixed appearance and ulceration, should be referred for biopsy. A persistent erythroplakia is an early manifestation of oropharyngeal squamous cell cancer.
Aspiration pneumonia is the major reason for hospital admission from nursing homes and has a mortality rate of 20% to 50%. Risk of aspirating increases when frail patients are dependent for assistance with feeding and oral hygiene. Patients with poor oral health have an increased risk for aspiration pneumonia. Improving oral hygiene decreases the bacterial load and results in a 40% reduction in aspiration pneumonia. Postural adjustment, allowing extra time for feeding assistance, feeding smaller quantities per bite, and instructing patients to chew longer prior to swallowing reduces the risk for aspiration.
Saliva should be free flowing and watery. It lubricates the intraoral tissues and the lips facilitating speech, taste, mastication, and swallowing. It decreases the risk of dental caries and periodontal disease. Saliva contains antimicrobial elements that modulate plaque formation, buffer intraoral pH against bacterial acid production, and promote re-mineralization of tooth surfaces with calcium and phosphate salts to repair incipient caries. In normal aging, the amount of saliva remains stable. However, saliva becomes thicker as a result of a reduction in serous flow relative to mucous, resulting in decreased lubrication.
Xerostomia resulting from decreased salivary flow or changed salivary composition affects 10% to 40% of older adults, seriously impairs oral function, promotes dental caries and exacerbates periodontal disease. Xerostomia is associated with autoimmune diseases such as rheumatic disease, Sjögren syndrome; and after chemo-/radiation therapy. In addition, decreased salivary flow is a side effect of 500+ medications, including tricyclic antidepressants, antihistamines, antihypertensives, and diuretics. Oral lubricants and salivary substitutes may be used as needed. However, relief is temporary, and they provide none of the protective properties of saliva. Any of several nonprescription oral lubricants and salivary substitutes are readily available.
Bone antiresorptive agents currently include IV and oral bisphosphonates and the recently approved denosumab. All are associated with osteonecrosis of the alveolar bone (ONJ). Cancer patients receiving IV bisphosphonates or denosumab minimize the risk of developing ONJ by receiving a thorough dental evaluation and completion of all dental treatment prior to initiating therapy. During bone antiresorptive therapy, excellent daily oral care, no smoking, limited alcohol consumption, no invasive dental procedures, and dental hygiene maintenance appointments every 3 months are recommended. Evidence of ONJ requires an immediate referral to an oral surgeon for therapeutic and palliative care. Denosumab-related ONJ may resolve more rapidly with a drug holiday than bisphosphonate-related ONJ because the pharmacodynamics and pharmacokinetics of the 2 classes of bone antiresorptive agents differ.