US Pharm. 2007;32(6):29-33.
Oral diseases increase in prevalence with age and are often complicated by comorbidities, including chronic systemic diseases, and medications. An oral–systemic disease connection has been reported in the literature. Furthermore, periodontal diseases have been associated with cardiovascular disease, diabetes mellitus, and respiratory infection, which may be more commonly seen in the older adult.1,2
In any population, including the elderly, tooth loss and dental caries are used as measures of oral health status.3 Additionally, other oral diseases that are evaluated are periodontal diseases, xerostomia, orofacial pain, and oral and pharyngeal cancer.3
The elderly have experienced varying levels of oral health care. In many cases, oral health care may be unobtainable due to low economic status, social isolation, residence in a long-term care institution, transportation limitations, or complex medical conditions.4
Many issues are involved in the oral health of older adults, including identification and control of risk factors, recognition and treatment of the manifestations of oral diseases, use of dental care services, and involvement of pharmacists in oral health education and management.
Use of Dental Services Among Older Patients
Obtaining dental care is different for elders who live independently and who are not institutionalized than it is for those who are homebound. In some communities, mobile dentists are available to visit homes and nursing homes to provide dental care. This has increased the number of elderly individuals who use dental services. Routine visits to a dentist allow for an assessment of the teeth, gums, and soft tissues, which is important in the detection, prevention, and treatment of oral health conditions.5 Even older patients who are edentulous (no teeth) must have routine dental visits to evaluate soft tissues and proper fitting of dentures. If there are no acute conditions that need to be closely monitored, annual visits are considered to be an appropriate time interval.5
Although a certain portion of the elderly population does not regularly visit the dentist, either because of personal choice or the inability to be transported, about 60% who are dentate (with teeth) actually have routine dental care, compared with 65% of younger individuals.6 On the other hand, only about 15% of elderly persons with missing teeth make annual visits to the dentist.6
The Aging Dentition
It is estimated that by 2050, the number of Americans age 65 and older will increase to about 48 million.7 With more people living longer, there will also be an increase in the prevalence of systemic and oral diseases. There is controversy over whether the physiologic and pathologic changes that occur with aging are due to the aging process itself or to diseases, medications, or environmental changes.8
Risk Factors for Poor Oral Health
Risk factors for poor oral health in the elderly include race, socioeconomic status, systemic illness, dentition status, medications, oral cancer, periodontal diseases, and dental caries. Some risk factors, such as smoking, can be modified, while others, such as genetics, cannot.9
The availability of dental insurance has been found to be a significant predictor of dental care utilization.10 Many older people are retired and live on a fixed income without private dental insurance, which may prohibit the use of dental services; most elders lose their dental insurance when they retire. Medicare does not cover routine dental services, and Medicaid provides only limited coverage in certain states.11 In addition, many elderly persons who are confined to their home because they are disabled or do not have a means of transportation are not able to visit a dentist. Only about 5% of the population who are older than 65 live in long-term care facilities, and about 5% to 10% are homebound.6 In many communities, bus transportation or mobile dentists who make house calls are available for these individuals.
Xerostomia (dry mouth), which is a risk factor for dental decay (caries) and periodontal disease, is due to lack of saliva either from disease, age, or use of medications such as antidepressants, antipsychotics, urinary antispasmodics, diuretics, beta-blockers, bronchodilators, gastrointestinal agents, anticholinergics, and anti-Parkinson's disease agents. The pharmacist or dentist should communicate with the individual's physician about either switching the medication to a similar drug with a different classification that has less xerostomic side effects or lowering the dosage. Table 1 lists products that can help relieve the symptoms of xerostomia.
Oral health problems including ill-fitting dentures, number of teeth present, deep caries, periodontal disease, or other oral infections may cause extreme pain and discomfort and interfere with proper eating. Elders with fewer posterior teeth demonstrate a lower dietary inake.12
Manifestations of Oral Diseases
It has been established that the two primary oral conditions--caries and periodontal disease--are worldwide oral infections with potentially serious consequences, especially in the elderly.13
Periodontal Disease: Periodontal disease (gingivitis, periodontitis) is an infectious disease characterized by bacterial accumulation in the gingivae (gums). As the bacteria mature, they release substances, including toxins and enzymes that cause direct destruction of the periodontal tissues (gingivae and bone), and stimulate the host to activate a local inflammatory response, which attempts to eliminate the infection but can also cause more destruction. Thus, the pathogenesis of periodontal disease is both inflammatory and immunologic.
Although age may be associated with some moderate loss of bone and soft tissue attachment,14 it is suggested that the progression of disease experienced in older adults may be due to time rather than aging.9,15
The primary risk factors for periodontal diseases are poor oral hygiene and smoking. There has been an increase in public awareness of a connection between certain systemic conditions and periodontal disease. Older individuals who have periodontal disease also have an increased incidence of cardiovascular disease, pneumonia, diabetes, and emphysema.16 It is important for physicians, dentists, and pharmacists to be aware of this oral–systemic disease connection.
Increased levels of plasma C-reactive protein (CRP), a marker for inflammation, are present in patients with periodontal disease and cardiovascular disease. Bacteria enter the blood when diseased tissues are more fragile during mastication, tooth brushing, or dental procedures. This bacteremia may result in systemic cardiovascular effects.17 Periodontal treatment can reduce levels of CRP.
A relationship between periodontal disease and the development of diabetes has been well established.18 Furthermore, having diabetes is associated with an increased incidence of periodontal disease.19,20 Therefore, treatment of periodontal disease is of the utmost importance, since it can help reduce the development of diabetes; and conversely, controlling diabetes can help reduce the development of periodontal disease.
Evidence exists to support an association between poor oral health, oral microflora, and bacterial pneumonia.21 Controlling or reducing oral biofilms may reduce the incidence of bacterial pneumonia.
Dental Caries/Root Caries: Nearly one third of persons older than 65 have untreated dental caries.5 Untreated tooth decay may result in pain that interferes with proper oral and general health and even tooth loss. Root caries occur when the gingiva has receded, exposing the root surface to the oral environment. Receded gingivae may also contribute to dentinal hypersensitivity (i.e., increased cold sensitivity in the tooth).
Orofacial Pain: Orofacial pain that occurs around the mouth and face can be severely debilitating, affecting a patient's ability to chew and swallow, as well as his or her dental care. Certain conditions that can cause orofacial pain include trigeminal neuralgia, postherpetic neuralgia, headache, and arteritis.
Oral and pharyngeal cancer is most prevalent in people age 65 and older, especially if they smoke and/or drink. Survival improves when the cancer is diagnosed in the early stages.
Dental Care in the Elderly
For the severely compromised and homebound or institutionalized elder, periodontal prevention and supportive therapies may be effective and appropriate when delivered by a dental professional and followed by adequate personal care by the patient or caregiver. Select oral health care products are listed in Table 2.
Toothbrushes are more effective in daily oral care than the foam tooth cleaners that are often found in nursing homes or institutions. Older individuals should be counseled on proper toothbrush selection and care. Soft-bristled toothbrushes are recommended rather than medium- or hard-bristled brushes, because they are less abrasive on the gingival and tooth structure. Electric toothbrushes are just as effective as manual brushes and are recommended if the patient has difficulty with hand coordination. It is recommended to use fluoride toothpaste to help prevent dental decay. Because dental floss may be difficult for many elders to manipulate, electric interdental cleaners are available. In addition, adjunctive fluoride rinses or gels are recommended in older patients who are prone to caries.
Mouth rinses with alcohol should not be recommended in elders with xerostomia or a history of oral cancer; most products contain varying percentages of alcohol that can dry the oral mucosa. Antigingivitis/anti plaque oral rinses can be used as an adjunct to flossing and brushing in elders who have difficulty manipulating floss and toothbrushes.
Special toothbrushes and products for cleaning dentures are available. Elders should be instructed not to sleep with dentures; dentures should be soaked in water or a cleaning solution overnight. If the denture is not fitted properly, or if there are red areas underneath the denture, the patient should visit a dentist.
Programs: Emphasis is being placed on effective oral health care prevention programs. The CDC is supporting state-based programs to promote oral health and has Web-based information systems such as the National Oral Health Surveillance System (www.cdc.gov/nohss).
The Pharmacist's Role in Oral Health
Elderly Americans are living longer than ever before. Thus, in addition to regular medical visits to a physician, routine dental visits to a dentist should be incorporated into an elder's care program. The responsibility of providing oral health care to elders who are independent, in a hospital, or in a nursing home lies with all health care professionals involved in patient care.22 The pharmacist is in a unique position to enhance oral health, because many elders talk to and confide in their pharmacist. Daily oral care should be reviewed with the elderly patient and should be established as a standard of care. The pharmacist can also recommend oral health care products, since there are many OTC products to choose from.
If changes in oral health--such as bleeding, pain, loose teeth, or soft-tissue lesions that have not healed--are noticeable, the patient should be referred to a dental specialist. Routine dental monitoring may help reduce the incidence of many systemic conditions, including cardiovascular disease, diabetes, and pneumonia.
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