The traditional Jewish blessing, "May you live to be 120," may be a realistic goal for many people one day. It was for the oldest documented person, Jeanne Calment. She died on Aug. 4, 1997, in Arles, France, at 122 years and 164 days.1 Born Feb. 21, 1875, Ms. Calment met painter Vincent van Gogh in 1888, was 14 years old when the Eiffel Tower was completed and took up fencing when she was 85 years old.
The proportion of older adults is increasing around the world. In the United States, the number of adults older than 65 years of age is expected to nearly double over the next 25 years. Projections show there will be as many people 85 years of age or older as there will be people 65 to 69 years of age by 2050.2
The "aging of America" has become a new catch phrase. As the baby boomers grow older, issues such as menopause and retirement benefits become hits on the nation’s radar screen. Health care for older adults is at the forefront of the American mind; in most cases, however, health care discussions often exclude the mouth. It seems that too many people still associate aging with losing teeth, wearing dentures and no longer needing to see dental care providers. Nothing could be further from the truth.
Older Americans are a heterogeneous group with specific concerns related to oral health care. Regular dental visits for older adults are imperative, yet many avoid them or are not aware of their importance. People with few or no teeth—many of whom have pros-theses—may believe that dental care no longer is relevant to them.
Older people who retain their teeth also may have barriers to obtaining oral health care, including financial or transportation problems (for independently living people) or reduced access to care providers (for some dependent people living in nursing homes or other assisted-living situations).
Other diseases and conditions—and the medications prescribed for them—also have effects on oral health. Many drugs cause xerostomia, which can lead to oral complications. Conditions such as diabetes, hypertension and obesity can affect the teeth and oral cavity. While these effects may help in the diagnosis of such conditions, they complicate oral health care.
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PROSTHESES AND HEALTH
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According to a 1996 survey of U.S. dentists, 53 percent of patients older than 65 years of age still have more than 20 natural teeth.3 Over the last five years, toothlessness declined 39 percent among people in this age group. Although more older Americans are keeping their teeth than ever before, many people have a full or partial set of dentures and may have reduced chewing capacity—as low as one-sixth that of people who do not have dentures. People who have ill-fitting prostheses, those who experience pain wearing them and people who need dentures but do not have them are at an increased risk of experiencing malnutrition.4
Even well-fitting partial dentures may increase a person’s risk of developing oral diseases. For example, patients with removable partial dentures are more likely to have untreated root caries than are patients without partial dentures.5 This may be due to an increased likelihood of biofilms that form and "prosper" in people who wear removable prostheses because they do not adequately or regularly clean their dentures.6 Other researchers have found that denture wearers are more likely to be diagnosed with other oral complications, such as stomatitis.7
Many patients with full dentures may not believe they need to visit a dental care provider unless they have a problem with their prostheses. Regular dental care, however, is essential for everyone’s oral health. For example, more than 30,000 cases of oral cancer are reported each year; one-half of which are in patients older than 65 years of age.8 Early diagnosis of any cancer will increase the chances of survival, and dental health care providers are in a prime position to identify symptoms that may lead to such a diagnosis.
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BARRIERS TO CARE
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Older adults are more likely to have chronic conditions that may affect their oral health, but they are less likely to visit a dental care provider than are younger adults.9 Many chronic health conditions affecting older adults lead to functional dependence in which people require assistance with their daily living activities. Living situations for functionally dependent adults include nursing homes, assisted-living facilities and home care. All of these situations would seem to be ideal for the administration of oral health care, but this is not the case. Functionally dependent older adults are less likely than independent adults to have seen a dental care provider in the past year. In a survey of 1,375 Canadian adults 85 years of age or older, only 31 percent of dentate nursing home residents had received dental care in the past year, compared with 47 percent of independently living adults. Nearly one-half of the nursing home residents had untreated root caries, 45 percent required tooth extraction, and 56 percent required prosthodontic treatment.10
Frail and functionally dependent adults have historically high levels of oral complications. In a survey of more than 250 functionally dependent adults (44 percent of whom were older than 80 years), nearly three-fourths reported difficulty in chewing in the previous four weeks, one-fifth reported oral pain, and more than 70 percent reported some incident of oral discomfort. Interestingly, only 30 percent expressed a desire for treatment.11 It may be that older adults expect their oral health to deteriorate as part of the aging process and that they must somehow "live with the pain." Health care providers can help dispel these myths and help all people understand that regular visits for oral preventive care can contribute immensely to overall quality of life.
Functionally dependent older adults are less likely than independent adults to have seen a dental care provider in the past year.
Functionally dependent adults not only have complex medical needs but also may not have the skills necessary to self-administer preventive dental care. Thus, any oral care visit should include an assessment of a person’s ability to perform oral hygiene and the provision of information and education when necessary. Education is stressed in young children, but should be a part of dental care visits for all age groups. An 18-month preventive program in a Swiss long-term care facility—which included an oral hygiene course for care providers—reduced the colonization of Streptococcus mutans and reduced caries prevalence.12
Personnel who work with dependent elderly people also benefit from education and knowledge. A Swedish study of nearly 400 nursing personnel who worked with dependent elderly people and severely disabled patients found that oral care assistance is viewed as more disagreeable than other nursing activities.13 Those most likely to be involved in daily oral hygiene—nursing assistants and home care aides—were least likely to view oral care assistance in a positive light.
Access to care may be a factor as well. Although nursing home care is a growing and profitable industry—$70 billion in U.S. revenues in 1993—a survey conducted in 1995 found that not all nursing homes offer dental services.14 Among 16,700 surveyed nursing homes in the continental United States, the following information was found:
- – about 1,700 did not offer any dental services;
- – sixty percent did not have the services of dentists or had dentists only on call or off site;
- – more than 1,000 nursing homes did not provide oral hygiene assistance to residents.14
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COMPLICATIONS AND RISKS
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Unfortunately, the cause-and-effect relationships between poor oral health and other diseases and conditions in older adults work both ways. Poor oral health can increase the risk of systemic disease and conditions or may result from systemic diseases.
In frail elderly people, poor oral health has been found to increase the risk of developing a respiratory tract infection,15 and may increase the risk of developing pneumonia and other systemic infections.16 Evidence suggests that oral bacteria can be aspirated into the lungs, leading to pneumonia. Typical respiratory pathogens have been shown to colonize the dental plaque of hospitalized intensive care and nursing home patients, increasing their risk of developing systemic infections.17 It may be possible, however, to reduce elderly people’s risks of developing pneumonia by improving their oral health. Techniques used to reduce the risk of developing pneumonia in postsurgical settings—such as prerinsing with chlorhexidine mouthwash and prescribing antibiotics to be used to fight gut-associated bacteria—have been successful, but they have not been studied in assisted-living settings.
Chronic conditions are prevalent among older people. More than one-half of people 70 years of age or older have some form of arthritis, and approximately one-third have high blood pressure.18 Many systemic diseases and conditions such as immunodeficiency and vitamin deficiency are manifested in the mouth; this means that dental care providers can play a key role in diagnosing chronic disease in older people. Oral cancer is much more common in people older than 40 years of age and often goes unnoticed at its earliest—and most curable—stages.
Some chronic conditions—or the medications used to treat them—can lead to xerostomia. Until recently, dry mouth was considered a normal consequence of aging, but now it is known that healthy older adults produce as much saliva as younger adults. Dry mouth may be a result of medications or cancer therapy (such as radiation to the head or neck), or it may have another cause or multiple causes.
HIV is relatively common in older adults but is not often associated with them. Approximately 11 percent of all AIDS patients, however, are 50 years of age or older, and within this group, one-fourth are 60 years of age or older.19 Older adults are more likely than younger adults and children to be diagnosed with HIV later in the course of the disease and, thus, also are more likely to die within one month of diagnosis.
Part of this inequity lies with health care professionals, who may be less likely to consider such a diagnosis in an older person. A survey of more than 300 general dentists found that a significant proportion never or rarely recognized complications of HIV in their patients or discussed the disease with them. Of these dentists, almost 80 percent felt they had inadequate information on HIV in older adults. Older adults are less informed about the disease; more than three-fourths of adults 50 years of age or older do not believe they are at risk of acquiring HIV, and 16 percent do not know its risk factors.19 Communication is needed on this topic among dentists, other health care professionals and older patients to encourage patients and health care providers to work together toward a common goal of improved health and quality of life.
To be fully effective in aiding in the diagnosis of chronic diseases with oral manifestations, we must keep open minds, revisit assumptions and continue our education.
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CONCLUSION
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Poor oral health is not an inevitable consequence of Social Security eligibility. Most changes in oral health in this older population are consequences of comorbid conditions, pharmacotherapy, functional disabilities or cognitive impairment and their results: reduced self-care, access to preventive care or both.9
Geriatric care is multidisciplinary and team-centered and focuses on maximizing a person’s functional performance, independence and quality of life. As dental care providers, we have an important place on this team.
The future of oral health care in older adults is nearly limitless. By the year 2020, 20 percent of Americans will be 65 years of age or older. As we begin to better understand the normal aging process and appreciate the changes caused by chronic diseases and conditions experienced by many older adults, we also can understand how these conditions interact with oral health and dental treatment planning.
Mature Americans seek to live longer and better. Oral health education, promotion and disease prevention will remain important parts of this into the 21st century.
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PROSTHESES AND HEALTH
BARRIERS TO CARE
