Maintaining Oral Health in Older Adults

The most recent United States census estimates the number of adults age 65 and older is expected to reach 98 million, or 24% of the overall population, by 2060.¹ This demographic change will impact the delivery of both medical and dental care. As the older adult population is retaining more teeth, data trends show that caries risk will also increase dramatically.²

The prevalence of caries in the US is significant among all Americans, but that of older adults is especially concerning. A recent National Health and Nutrition Examination Survey found that 96% of adults age 65 and older have caries experience, and one in five have untreated tooth decay.³ While more untreated caries is seen in those with lower incomes and less education, individuals with higher incomes and more education have actually experienced more decay, with an average of 9.24 decayed teeth or missing teeth and 43.02 decayed or missing tooth surfaces.⁴

ROOT CARIES

More than one-third of the US population experiences root caries, and older adults are particularly affected.^5,6 These lesions present below the cementoenamel junction of a tooth on the root surface, affecting cementum and dentin.⁵ If root caries lesions go undetected or are left untreated, they can eventually lead to edentulism, chronic or acute pain, impaired mastication, and reduced quality of life.^2,7

NUTRITION

Aging adults may experience dysgeusia, diminished taste, and loss of smell, which may impact their nutritional intake. As senses of taste and smell diminish, individuals may change their dietary choices. Diminished taste can cause food to taste bitter and sour; to compensate, patients may add more sugar and salt. Nutrition or meal replacement shakes or dietary supplements may be introduced due to malnutrition or digestive issues. These alternatives are often cariogenic due to high sugar and acid content.⁸

XEROSTOMIA

Older adults are more susceptible to xerostomia, which is a risk factor for caries.⁹ Patients with decreased salivary function are at risk for developing new or recurrent caries. Saliva has the ability to buffer acidity in the oral cavity, and therefore is integral to the prevention of tooth demineralization. It also acts as an antimicrobial and decreases the number of cariogenic bacteria.⁹

The risk of xerostomia is particularly high in this population due to the increased likelihood of polypharmacy. Polypharmacy is defined as taking more than one medication at a time, and is common among older adults.¹⁰ Throughout the aging process, the number of systemic medical conditions grows. Having more than one health concern or certain conditions, such as cancer, will likely lead to polypharmacy and advanced medical treatments such as radiation therapy.¹⁰ Radiation therapy used to treat head and neck cancers can rapidly increase caries risk. Patients undergoing radiation therapy are at risk for xerostomia, caries, periapical periodontitis (inflammation around the apex of a tooth most likely caused by untreated caries), enamel erosion, and dentin exposure, even months after treatment.¹¹ Other indirect effects of radiotherapy include changes in salivary quantity and composition, along with alteration of the oral flora, which are predisposing causes of radiation caries.¹¹

Patients with systemic and medical conditions should be educated about the possible side effects of xerostomia. Many patients with autoimmune diseases, such as rheumatoid arthritis and Sjögren syndrome, experience xerostomia.^12,13 A 2017 study found that more than 50% of those with rheumatoid arthritis experienced xerostomia.^12,13 Reduced manual dexterity related to rheumatoid arthritis may also contribute to caries progression.² Sjögren syndrome occurs more commonly in women and is typically detected around the age of 50, surging around menopause. Patients with Sjögren syndrome experience a decrease in salivary gland secretion activity due to the destruction of exocrine glands.¹⁴

Menopause also leads to reduced estrogen levels, which can diminish salivary flow, leading to symptoms of xerostomia, burning mouth syndrome, and dysesthesia. These alterations in the oral mucosa can lead to poor choices in diet and, ultimately, caries.¹⁵ Because saliva acts as a defense mechanism for caries prevention, making the necessary changes to patients’ self-care during menopause is important.¹⁶

Oral health professionals should educate older adults on lifestyle modifications that can help reduce xerostomia, such as drinking water throughout the day and avoiding alcohol and caffeine. To reduce the effects of xerostomia, the use of products containing fluoride, calcium phosphate, xylitol, including orally adhesive discs, and arginine; chewing sugarless gum; and consuming vitamin C may be recommended. Prescription medications, or sialagogues, to increase salivary flow may also be indicated.¹⁷

PREVENTION AND TREATMENT OPTIONS

When treating older adults, prevention and behavioral change are key, as more advanced treatment may not be feasible due to socioeconomic factors and health restraints.¹⁸ In cases where advanced restorations are present, customized self-care considerations are recommended. Prosthetic-retained teeth, clasps on partial dentures, crown margins, furcations, and interproximal surfaces of fixed prostheses can make it difficult for patients with limited manual dexterity to effectively remove biofilm.¹⁹ Patients with restorations need to be consistently motivated to maintain routine preventive dental visits. In the elderly demographic, restoration survival times are shorter than among younger individuals.^2,20,21 Therefore, caries prevention and noninvasive treatments should be strongly considered.²² Dental care is often overlooked among older adults, with medical care taking precedence.^2,23 Interprofessional collaboration, along with patient communication, is crucial to determining the needs of older adult patients.¹⁶

Strategies for caries prevention and management include individualized self-care instructions, in-office treatments to remove biofilm accumulation, fluoride treatments, glass ionomer applications, and recommendations for products that stimulate salivary function.²⁴ In addition, proper and efficient oral hygiene is necessary to reduce caries. Research has proven that the relationship between oral behaviors and overall health has long-lasting, significant effects.⁵

Fluoride is the gold standard in caries prevention.²⁵ The American Dental Association recommends the use of 5,000 ppm fluoride (1.1% sodium fluoride) toothpaste or gel at least once per day for nonrestorative treatment of carious lesions.²⁶ When compliance is low, application of 5% sodium fluoride varnish is recommended.²⁶

In 2016, the US Food and Drug Administration approved the use of silver diamine fluoride (SDF) as a dentin desensitizer. After clinical trials documented its ability to arrest caries lesions, SDF is often used off-label for this purpose.²⁷ SDF is a good option for older adults in the arrest of caries, as it is noninvasive, painless, and simple to apply, especially in patients for whom receiving traditional oral healthcare is difficult.²⁸

While fluoride remains the gold standard in caries prevention, some patients decline its use. Nonfluroide caries preventive agents are available, although they do not have a wealth of scientific evidence supporting their effectiveness. Older adults averse to fluoride use or at high risk of caries may be encouraged to try products containing xylitol, baking soda, chlorhexidine, arginine, tricalcium phosphate, amorphous calcium phosphate-casein phosphopeptide, triclosan, and iodine to help reduce their caries risk.²⁹

ACCESS TO CARE

Older adults seeking oral healthcare may face myriad barriers. The cost of dental care is a significant concern, as many older adults live on fixed incomes, do not have dental insurance, and Medicare does not cover routine dentistry.³⁰ In 2017, the National Health Interview Survey found that only about 29% of adults age 65 and older had dental insurance, and approximately two-thirds had received dental treatment in the previous year.²³ Increasing access to care can help maintain tooth function, improve overall quality of life, and prevent premature morbidity and mortality.³¹ The need for appropriate dental care is especially important in this population as older adults are at increased risk for age-related physiologic changes. Oral health professionals must be prepared to manage the oral health needs of older adults with complex medical, functional, and dental disabilities.

CONCLUSION

Oral health professionals are charged with helping older adults maintain their oral health. Evaluating the likelihood of compromised self-care and developing alternative strategies are an important part of treatment planning.³⁰ Preservation of functional dentition through caries prevention is associated with better quality of life. As the life expectancy of the aging population continues to increase, oral health professionals play an integral role in the awareness, promotion, and enhancement of oral health in this population.³²

REFERENCES

1. Colby SL, Ortman JM. Projections of the Size and Composition of the US Population: 2014 to 2060. Available at: census.g/​v/​library/​publications/​2015/​demo/​p25-1143.html. Accessed August 24, 2020.
2. Tonetti MS, Bottenberg P, Conrads G, et al. Dental caries and periodontal diseases in the ageing population: call to action to protect and enhance oral health and well-being as an essential component of healthy ageing—Consensus report of group 4 of the joint EFP/​ORCA workshop on the boundaries beJ J Clin Periodontol. 2017;44:S135–S144.
3. Dye BA, Thornton-Evans G, Xianfen L, Iafolla TJ. Dental caries and tooth loss in adults in the United States, 2011-2012. NCHS Data Brief. 2015;197:197.
4. National Institute of Dental and Craniofacial Research. Dental caries (tooth decay) in seniors (age 65 and over). Available at: nidcr.nih.gov/​research/​data-statistics/​dental-caries/​seniors#table4. Accessed August 24, 2020.
5. Zhang J, Sardana D, Wong MCM, Leung KCM, Lo ECM. Factors associated with dental root caries: a systematic review. JDR Clin Trans Res. 2020;5:13–29.
6. Griffin SO, Griffin PM, Swann JL, Zlobin N. Estimating rates of new root caries in older adults. J Dent Res. 2004;83:634–638.
7. Jepsen S, Blanco J, Buchalla W, et al. Prevention and control of dental caries and periodontal diseases at individual and population level: consensus report of group 3 of joint EFP/​ORCA workshop on the boundaries between caries and periodontal diseases. J Clin Periodontol. 2017;44:S85–S93.
8. Rodrigues Jr HL, Scelza MRZ, Boaventura GT, Custodio SM, Moreira EAM, Oliveira DDL. Relation between oral health and nutritional condition in the elderly. J Appl Oral Sci. 2012;20:38-44.
9. Singh ML, Papas A. Oral implications of polypharmacy in the elderly. Dent Clin North Am. 2014;58:783–796.
10. Stier K, Stefanou LB. The etiology of xerostomia. Dimensions of Dental Hygiene. 2019;17(7):50–53.
11. Lu H, Zhao Q, et al. Direct radiation-induced effects on dental hard tissue. Radiat Oncol. 2019;14:5.
12. Stefanski AL, Tomiak C, Pleyer U, Dietrich T, Burmester GR, Dörner T. The diagnosis and treatment of Sjögren syndrome. Deutsches Aerzteblatt International. 2017;114:354–361.
13. Chamani G, Shakibi MR, Zarei MR, et al. Assessment of relationship between xerostomia and oral health-related quality of life in patients with rheumatoid arthritis. Oral Diseases. 2017;23:1162–1167.
14. Saccucci M, Di Carlo G, Bossù M, Giovarruscio F, Salucci A, Polimeni A. Autoimmune diseases and their manifestations on oral cavity: diagnosis and clinical management. J Immunol Res. 2018;6061825:1–6.
15. Anil S, Vellappally S, Hashem M, Preethanath RS, Patil S, Samaranayake LP. Xerostomia in geriatric patients: a burgeoning global concern. Journal Investigat Clin Dent. 2016;7:5–12.
16. Suri V, Suri V. Menopause and oral health. J Midlife Health. 2014;5:115–120.
17. Hunt AW. Dahm T, Bruhn AM. Strategies for treating seniors. Dimensions of Dental Hygiene. 2018;16(8):41–44.
18. Razak PA, Richard KM, Thankachan RP, Hafiz KA, Kumar KN, Sameer KM. Geriatric oral health: a review article. J Int Oral Health. 2014;6:110–116.
19. Giusti L, Steinborn C, Steinborn M. Use of silver diamine fluoride for the maintenance of dental prostheses in a high caries-risk patient: A medical management approach. J Prosthet Dent. 2017;119:713–716.
20. Stewardson DA, Thornley P, Bigg T, et al. The survival of Class V restorations in general dental practice. Part 2, early failure. Br Dent J. 2011;210:E19.
21. Gil‐Montoya JA, Mateos‐Palacios R, Bravo M, Gonzalez‐Moles MA, Pulgar R. Atraumatic restorative treatment and Carisolv use for root caries in the elderly: 2‐year follow‐up randomized clinical trial. Clin Oral Investig. 2014;18: 1089–1095.
22. Schwendicke F, Stolpe M, Meyer‐Lueckel H, Paris S. Detecting and treating occlusal caries lesions: a cost‐effectiveness analysis. J Dent Res. 2015;94:272–280.
23. Kramarow EA. Dental care among adults aged 65 and Over, 2017. Available at: cdc.gov/​nchs/​products/​databriefs/​db337.htm. Accessed August 24, 2020.
24. Featherstone J, Singh S, Curtis DA. Caries risk assessment and management for the prosthodontic patient. J Prosthodont. 2011;20:2–9.
25. Gluzman R, Katz RV, Frey BJ, McGowan R. Prevention of root caries: a literature review of primary and secondary preventive agents. Spec Care Dentist. 2013;33:133–140.
26. Slayton RL, Urquhart O, Araujo MWB, et al. Evidence-based clinical practice guideline on nonrestorative treatments for carious lesions: a report from the American Dental Association. J Am Dent Assoc. 2018;149:837–849.
27. Horst JA, Ellenikiotis H, Milgrom PL. UCSF protocol for caries arrest using silver diamine fluoride: rationale, indications and consent. J Calif Dent Assoc. 2016;44:16–28.
28. Oliveira BH, Cunha-Cruz J, Rajendra A, Niederman R. Controlling caries in exposed root surfaces with silver diamine fluoride: A systematic review with meta-analysis. J Am Dent Assoc. 2018;149:671–679.
29. Macri D. Implementing a multifaceted approach to caries prevention. Dimensions of Dental Hygiene. 2018;16(5):21–25.
30. Griffin SO, Jones JA, Brunson D, Griffin PM, Bailey WD. Burden of oral disease among older adults and implications for public health priorities. Am J Public Health. 2012;102:411–418.
31. Dolan TA, Atchison K, Huynh TN. Access to dental care among older adults in the United Sates. J Dent Educ. 2005;69:961–974.
32. Gati D, Vieira AR. Elderly at greater risk for root caries: a look at the multifactorial risks with emphasis on genetics susceptibility. Int J Dent. 2011;2011:647168.

From Dimensions of Dental Hygiene. September 2020;18(8):16,18, 21.