Oral health concerns in elderly: A review

Introduction

Throughout the world, a demographic revolution is underway as the proportion of older people is growing faster than any other age group and it becomes the mission of the health professionals to work not merely to increase the life span but also and perhaps more importantly, make later years of life more productive and enjoyable.¹ Elderly or old-aged consists of individuals with their ages nearing or surpassing the average life span of human beings.²

Oral diseases are complex, multi-factorial and progressive in nature. In the elderly, oral health status is generally poor due to several causative and controversial risk factors, and is usually characterized by increasing tooth loss, periodontal disease, and bad oral hygiene. Enhanced susceptibility to oral diseases is noted among the elderly population because of an increase in chronic medical conditions and the associated disabilities.²

This narrative review includes the classification, physiologic changes and prevalence of oral diseases, management and prevention as well as public health aspects for elderly.

Classification of elderly the“elderly”segment of the population.³

1.        People aged 65-74 years are the new or young elderly.

2.        People aged 75-84 years are the old or mid-old.

3.        People 85 years and older are the oldest-old.

Physiological changes in oral soft and hard tissues due to aging elderly

Enamel

The enamel endures both chemical and morphological changes through the years. These tissues become less hydrated and experiences superficial increase in fluoride content with age, especially with the use of dentifrice and tap water. Thickness of the enamel does change overtime, especially on the facial, proximal contacts and incisal and occlusal surfaces due to the many chewing cycles and cleaning with the abrasive dentifrices. Enamel abrasion and crystalline changes also contribute tothe changes in tooth appearance. The disappearance of the outer layer of the enamel overtime changes the way in which the tissue interacts with acidic solutions.⁴

Dentin

The volume of dentin decreases through the continuous apposition of secondary dentin on the walls of the pulpal chamber. Aged dentin is more brittle, less soluble, less permeable and darker than it was earlier in life.³ Darkening and yellowing is commonly observed and results primarily from changes in the thickness and composition of the underlying dentin. Odontoblast continues to form secondary dentin throughout life, moving towards pulp chamber. This continuing dentin production results in a progressively smaller pulp chamber and root canals. There is formation of tertiary dentin in response to trauma, caries or irritation.⁴

Pulp space

The number of blood vessel entering a tooth and the concentration of cells also appear to decrease with age. The capacity of pulp tissue to respond to trauma may thus, decrease whereas potential access for endodontic treatment becomes restricted. The size of the pulp chamber and volume of the pulpal tissue decreases with reparative and secondary dentin formation. The odontoblastic layer surrounding the pulp changes progressively from a multilayer organization of active columnar cells to a single layer of relatively inactive cubical cells. Calcifications of the root canal increases with age, and the cementum volume within the alveolus increases gradually overtime, notably in the apical and periapical areas.⁴

Periodontium

Cementum, the periodontal ligament, and alveolar bone make up the attachment apparatus of the periodontium. The thickness of the cementum layer, covering the root surface triples over one’s life time, placing cementocytes at a greater distance from essential nutrients and fluids. In decades past, it was believed that aging was a major factor in gradual destruction of the periodontium, periodontal disease. Current thinking is that this represents pathologic change. Although increasing age may be associated with greater risk of having experienced destructive periodontal changes, these are not features of physiologic aging. The fibre content of the periodontal ligament may decrease with age.⁵

Mastication

Chewing or mastication, of food is a complex biochemical process that has been understood to be significantly affected by increasing age.3 Although study of this area remains in need of standardization, significant efforts to quantify age- related impairments have been made. Measuring food particle size after timed chewing, with detailed instructions to subjects, has been the primary strategy to date. Studies using this approach have reported reduced chewing effectiveness with increasing age.⁵

Oral mucosa

Oral tissues like others change as an individual grows older. The oral mucosa of the aged is friable and easily injured. Even under the best circumstances, the cells of the aged do not enjoy the optimal nourishment and vitality of youthful cells. According to Massler, tissue friability arises from three sources: (i) a shift in water balance from the intracellular to the extracellular compartment and diminished kidney function results in dehydration of the oral mucosa, (ii) progressive thinning of the epithelial layers which increase the tissue vulnerability to mild stresses and,(iii) nutritionally deficient cells. Oral varicosities are often noted on the under surface of the tongue, and in the floor of the mouth and are related to varicosities found elsewhere. The accumulation of lipids in the walls of these medium-sized sublingual arteries is theresult of the dietary risk factors such as high intake of saturated fats, cholesterol and sucrose.⁶

Tongue, taste sensation and salivaryfunctions

Probably the most common manifestation of aging of the tongue is depapillization, which usually begins at the apex and lateral borders. Tongue frequently becomes smooth and glossy or red and inflamed in appearance. As the age advances, the tongue seems to increase in size in the edentulous mouth and thus the greatest influencing factors in lower denture instability. The tongue loses its usual muscle tone and offers less resistance when palpated bidigitally.Salivary function was thought to decline with age, but it is now accepted that the production of saliva and its composition are largely age independent in healthy people.⁶

Prevalence of oral diseases in elderly   

The epidemiological literature on oral health in the elderly is not very encouraging, and it indicates profound imbalances among countries and regions and as a function of institutionalization. This disparity is mainly attributable to differences in socioeconomic conditions and in the availability of and access to oral health services.⁶

Tooth loss has also been linked with increased risk of ischemic stroke and poor mental health. On the other hand, older adults are more susceptible to oral conditions or diseases due to an increase in chronic conditions and physical/mental disabilities. Despite the lack of definite evidence supported in the literatures, some dental factors such as improperly fitting denture, electro galvanism, edentulism, sharp teeth, mouthwashes and poor oralhygiene have been announced as probable causes of oral precancerous and cancerous lesions.³

Epidemiological data on periodontal disease (a chronic infectious disease that affects tooth support tissues, including gingiva and alveolar bone) has shown that the most frequent findings among the elderly are the accumulation of bacterial plaque with consequent gingivitis and mild or moderate alveolar bone loss (1.8% had no signs of periodontal disease and 3.3% showed severe periodontal lesions). According to a recent systemic review of studies from 37 countries,22 although the incidence of severe periodontitis (greater likelihood of tooth loss) was higher with increasing age, it was low and fairly constant among the elderly.⁷

A high prevalence of xerostomia and salivary gland hypofunction has been found in vulnerable elderly people.The prevalence increases with older age, and oral cancer is of particular concern among over-65-year-olds. Variations among countries are attributable to differences in risk profiles and to the availability of and accessibility to health services, among others.⁸

The oral manifestations of Iron deficiency anemia are glossitis and fissures at the corners of the mouth. Tongue thrusting associated with nervous tension or with attempts to control a lower denture can lead to a sore tongue.⁸

Vitamin A deficiency may be associated with such epithelial hyperkeratinization. If there are not systemic contraindications, increased use of condiments might provide more flavour to the food.⁶

Glossodynia and glossopyrosis are common complaints in senescence. These symptoms are usually attributed to the nutritional deficiencies of folic acid, vitamin B12 and / or iron.⁶

The prevalence of these lesions in general population has been reported as 9.7% in Malaysia, 15.5% in Turkey, 25% in Italy, 61.6% in Slovenia, 15% of Saudi Arabian and 41.2% of Indian dental patients.⁹

India is a vast country with a population of more than one billion people. Of this, people older than 60 years constitute 7.6%. About 40% of the elderly live below the poverty line and 73% are illiterate. Almost, 90% of the elderly have no social security and the dependency ratio is 12.26.There are several factors that affect the oral health of elderly.  In 2004, the dentist population in India was 1:30,000 according to World Health Statistics. In 2014, the ratio was 1:10,000. Thus, these statistical ratio suggests that there is still not enough number of dentists in India.Incidence of oral cancer, which is considered an old-age disease, is highest in India. Also, 13.5% of all body cancers are oral cancers. Thus, old people form a distinct group in terms of provision of care.¹⁰

Common oral health diseases and conditions in elderly

Dental caries

Caries remains a major oral health problem among the elderly for various reasons: the increase in treatment and maintenance of teeth rather than their extraction; age-related salivary changes; a poor diet; exposure of the root surface by gingival recession; and a greater likelihood of drug treatment with xerostomia as a side effect.

Risk factors for dental caries in older persons aredecreased salivary flow rate, history of caries, institutionalization, lack of routine dental care, low socioeconomic status, non-fluoridated community water supply and poor oral hygiene.³

Periodontal disease

Although gingivitis is more common in older persons, age alone is not a risk factor for gingivitis or periodontitis. Gingivitis can be reversed with good oral hygiene.Many older persons are prone to periodontal detachment and tooth loss because of poor oral hygiene and gingival recession. Periodontitis has been associated with cardiovascular disease, worsening diabetes control, poor wound healing, and aspiration pneumonia, particularly in institutionalized patients.⁶

Treatment of periodontal disease includes daily brushing and flossing, and professional dental care, ranging from plaque removal to surgical debridement of infected periodontium. Oral antibiotics, such as doxycycline, have been used as adjuncts to scaling and root planing in older patients who are institutionalized. Along with regular dental cleanings, these interventions can reduce the need for surgical debridement and tooth removal.¹¹

Edentulism

When not treated, the final stage of caries and periodontal disease is tooth loss and eventually edentulism, which is highly frequent but represents a failure of the dental care system. Edentulism is directly related to mastication and nutritional problems. Some authors proposed that it may be a good mortality predictor, and others associated it with a substantive quality of life impairment.²

Dry mouth in the elderly

The greater life expectancy of populations has also increased the importance of dry mouth as a health issue. Etiologic factors include polymedication (especially with anti-hypertensives, antidepressants, and antipsychotics), poor general health, female sex, and older age. Current treatment approaches for management of xerostomia are directed toward providing relief of symptoms. They         include             gustatory,      masticatory    and pharmacologic stimulants, replacement therapies (mouth-wetting agents) and prevention of effects on oral health due to hyposalivation.¹¹

Oral candidiasis

Although it is estimated that Candida species are present in the normal oral flora of healthy adults, certain conditions increase the risk of overgrowth in older persons. These conditions include the pathogenicity of individual Candida strains; local factors (e.g., xerostomia, denture irritation, tobacco use,steroid inhaler use); and systemic factors (e.g., immunodeficiencies, systemic corticosteroid use, antibiotic use, chemotherapy, radiation therapy, endocrine disorders, malabsorption, malnutrition).

In patients who wear dentures, oral candidiasis may also lead to an erythematous lesion called denture stomatitis. Angular cheilitis is a manifestation of Candida albicans or Staphylococcus aureus infection. The condition is characterized by erythematous, scaling fissures at the corners of the mouth, is often associated with intraoral candidal infection, and typically occurs in patients with accentuated skin-folds and salivary pooling in the corners of the mouth.¹²

Oral candidiasis may be treated with topical or systemic antifungal therapy. Topical agents that are generally effective for treating uncomplicated infections include nystatin oral suspension or troche or clotrimazole troche.  In patients with denture stomatitis, a topical antifungal should be applied to the mucosa and denture base. If the dentures are ill fitting, a dentist may need to reline or surgically remove the excess tissue before constructing new dentures.¹²

Oral cancer

Oral cancer represents a major threat to the health of adults and the elderly in both high- and lowincome countries. Incidence and mortality rates are higher in men than in women. Oral cancer is frequently treated with surgery, radiotherapy, and/or chemotherapy, and advances have led to a reduction in the mortality rate and to an increased number of survivors.

A multidisciplinary approach is essential for reducing the impact on patients, with an important role for dentists. Dental care before, during, and after treatment can help to maintain or improve the quality of life of oral cancer patients.¹³

Prevention of oral diseases in elderly

Good manual dexterity and a person’s motivation are directly related to effective plaque removal. Diminished cognition, decreased visual acuity, or loss of strength or function in the hands may significantly alter a person’s ability to maintain good oral hygiene.³

The plaque retention in the elderly is exacerbated by the presence of restorations, missing teeth and gingival recession. The wearing of removable dentures may also negatively influence plaque accumulation. In addition, they often face difficulty in mechanical removal of plaque because of reduced manual dexterity or impaired vision or due to physical limitations associated with conditions such as stroke, Parkinson’s disease or severe arthritis. The elderly person should be helped to develop the ability to brush effectively and thoroughly.⁷

Oral Health Aids

Specialized oral health aids, such as electric toothbrushes, manual toothbrushes with widehandle grips, and floss-holding devices, may be necessary to remove plaque in patients with chronic disabling conditions, such as arthritis or neurologic impairment.¹²

The preferred method of brushing for most elders is sulcular brushing with soft toothbrush (Bass method). Persons with gingival recession should be instructed to observe certain precautions avoid further recession or cemental abrasion. These may include the use of an extra soft toothbrush, use of light pressure, modification of the brushing method.¹¹

A therapeutic rinse contains an agent that is beneficial to the tooth surface or oral environment. Therapeutic rinses may contain chlorhexidine, sodium benzoate, sanguinaria, a fluoride, or other demineralizing agents, which can enhance oral disease and should be recommended to the elderly when appropriate. Remineralizing rinses can be used in an elderly person who continually experiences new coronal or root carious lesions as a consequence of severe xerostomia. This replaces the calcium and phosphate lost from enamel or cementum. This is most effective when used with topical fluorides.¹¹

Denture care

Many edentulous elderly believe erroneously that once all their teeth have been extracted they no longer need to be concerned about oral health. The elderly who wear dentures should be taught proper home care of both dentures and tissues on which they rest as well as the need for continued professional care. The tissues can be prevented from harm by avoiding wearing the denture constantly. An instruction for the removal of the denture while retiring for the night is essential. The cleaning and massaging of the tissues under a denture at least once a day increases circulation and thus enhances the health of these tissues.³

Counseling and education

Preventive dentistry counseling for the geriatric patient includes two components – Education and Motivation. Patient education includes a discussion with the patient of the causes of current and pastoral disease and means of intervention and prevention of future disease. Discussion of etiology should be complete, but appropriate to the level of understanding of the individual elderly person.3When one is providing instruction in home care procedures, whether teaching the elderly person himself or a caregiver, a simple yet effective model the dentist should practice a simple yet effective model.⁷

Counseling and adherence

Possession of preventive knowledge and skills alone will not ensure the elderly person’s attainment of the goal of preventive counseling that is, maintenance of optimal oral health status. The dental professional and patient must establish a therapeutic alliance, whereby each is committed to performing the activities necessary to achieve this goal. The patient must be convinced that ultimately only he can help himself by adhering to the recommended preventive measures. The dentist should work to dispel the misconception that oral disease is an inevitable consequence of aging, and that; consequently, the attempt to prevent oral disease is a futile effort.³

Health initiatives for elderly in India

The Government of India has come up with the National policy for older people (1999), National council for older persons, National programme for health care of the elderly (NPHCE), Varistha Mediclaim policyand Helpage India (voluntary organizations)all attend to the health care needs of the elderly. Danta Bhagya scheme (2014), an initiative of Government of Karnataka, is a novel initiative aimed at distributing free dentures to completely edentulous citizens aged 45 years and above who have BPL cards.¹⁴

 Conclusion

Oral health is not only vital for appearance and a sense of well-being, but also for general health and quality of life in elderly individuals. Oral disorders are snowballing across the lifespan to an extent that adverse outcomes of oral conditions are likely to be the greatest among people in the later stages of life. Improving oral health will significantly enhance the physical, social and mental attributes of geriatric individuals.