Chris C.L. Wyatt, DMD, MSc, Michael I.

MacEntee, LDS, PhD

Dental caries in chronically disabled elders

ental caries is a bacterial infec- is multifactorial, necessitating

Dental caries is the major cause
tion caused by a complex exposed tooth structure subjected to
of tooth loss in elderly individuals
interaction of biological and high numbers of cariogenic bacteria
with physical and mental disabilities.
behavioral factors, and it is the major and fermentable carbohydrates over
The diagnosis of caries in elderly
cause of tooth loss in all age groups. a prolonged period. Tooth surfaces
individuals is difficult due to a com-
There is, moreover, mounting evi- exposed in the mouth undergo a nat-
plicated oral environment compound-
dence that the risk of caries infection ural process alternating between
ed by the prevalence of physical and
is particularly high in elderly individ- demineralization and remineraliza-
mental barriers to care. The restora-
uals with physical and mental dis- tion, and the process fails with the
tion of tooth structure and the
abilities. A chronically disabled per- development of a caries lesion when
replacement of teeth lost due to
son has either mental or physical lim- destruction exceeds repair. Caries
caries result in considerable econom-
itations, or both, and is probably tak- begins as a small demineralized area
ic and biological cost to both individ-
ing medications with xerostomic on the surface of the tooth which can
uals and society. Decisions to rem-
side-effects. In addition, chronic dis- progress through the enamel or
ineralize, restore, or extract teeth
ability usually precipitates a loss of cementum and dentin to the dental
depend largely upon the extent of
independence, reduced income, diffi- pulp. Lactic acid, a byproduct of
the structural damage caused by the
cult access to dental services, and microbial fermentation of dietary car-
infection. Teeth with small lesions
poor oral hygiene. A diagnosis of bohydrates, can demineralize tooth
can be remineralized with fluorides,
caries is made by clinicians usually structure, whereas calcium in the
whereas teeth with large lesions
after a visual and tactile examination saliva and fluoride applied directly
may be restored or extracted. Caries
of the teeth, but frequently without can reverse this damage. Although
risk assessment based on the histo-
an investigation of the factors that there is little histopathological dis-
ry of previous infection, salivary
contribute substantially to the initia- tinction between coronal and root
parameters, and ingestion of sugar
tion and virulence of the disease. lesions, demineralizationbf cemen-
can be used as a basis for placing a
This paper will address the patho- tum and dentin, in contrast to enam-
patient on a caries-preventive regi-
physiology of caries with a particular el, occurs at a slightly higher pH.If2
men. This paper dlscusses the patho-
focus on the diagnosis/measurement, Hence, severely abraded or eroded
physiology of caries to explain the
distribution, impact, and management crowns and roots are particularly
appropriate diagnosis, prevention,
of the infection to explain the ratio- prone to demineralizati~n.~?~
and treatment of dental caries in
nale for diagnosis, prevention, and Caries in elderly individuals usu-
elderly individuals with chronic dis-
treatment of the disease in elderly ally occurs on root surfaces5 proba-
abilities.
individuals with chronic disabilities. bly because of gingival recession,
medications with xerostomic side-
effects, and poor oral hygiene.6-10
Pathophysiology Demineralization of the tooth
All too often, the pathophysiology of requires three conditions on the sur-
dental caries is ignored by clinicians face for permanent damage to be pro-
in the rush to restore suspicious duced: (1)fermentable carbohy-
lesions, and rarely is there considera- drates; (2) a dense layer of cariogenic
tion for the dynamic environment of microflora, probably mutans strepto-
the mouth in which dental deminer- coccus and lactobacilli, to institute
alization and remineralization are the fermentation; and (3) time to dis-
normal processes. The cause of caries mantle the organic matrix.ll There is

196 SCD Special Care in Dentistry, Vol17 No 6 1997

evidence that Actinomyces viscosus
and Actinomyces naeslundii can initiate
root caries in animal^,'^-^^ but in
humans, mutans streptococcus and
lactobacilli appear to be the major ini-
tiators of coronal and root caries.15-19
Diagnosis/measurement
Caries lesions are found most effec-
tively on dry dental surfaces under
good illumination. Nonetheless, it is
difficult to distinguish between
infected lesions that are expanding
and surface defects due to a previous
infection.20It is very likely that the
lesion is expanding if it is soft and
easily penetrated by light probing
with a dental explorer,21,22or if there
is radiographic evidence that the
lesion extends into dentin.23This dif-
ficulty is exaggerated further on root
surfaces because of poor access for
examination and because lesions usu-
ally expand quite slowly around the
A careful examination of the teeth
for surface defects, however, is insuf-
ficient to complete the diagnosis
without considering four other fac-
tors that heighten the risk of caries:
(1)a history of previous infection, (2)
the number of cariogenic bacteria, (3)
the frequency of sugar ingestion, and
(4) a restricted flow of saliva.
History of previous infection
Multiple restorations in the teeth, evi-
dence of recent infection, and root
surfaces recently exposed from gingi-
val recession or periodontal surgery
are strong predictors of recur-
r ence?,27,28
Numbers of cariogenic bacteria
Poor oral hygiene is frequently asso-
ciated with high numbers of mutans
streptococci and Lactobacilli in the
dental plaque and in the
Consequently, the risk of caries is ele-
vated if a patient yields more than
lo6 colony-forming units (CFU) of
mutans streptococci or lo5 CFU lacto-
bacilli per milliliter of saliva.33
However, estimates of the number of
bacteria are probably more useful for
predicting the absence, rather than
the presence, of an active infection?*
Sugar ingestion
Consumption of refined carbohy-
drates, particularly sucrose, is com-
monplace in long-term-care (LTC)
facilities, where food is a major pre-
occupation. Unfortunately, frequent
snacks of sugar place the residents at
a very high risk for ~ a r i e s . ~ ~ ~ ~ * developed one or more caries lesions
Cariogenic foods can be identified in
the diet, but it is difficult to measure
total sucrose intake. However, the fre-
quency rather than the quantity of
sugar intake is associated more closely
with the virulence of the d i s e a ~ e ? ~ - ~ l
Unfortunately, it is difficult to mea-
sure food consumption; therefore,
only rarely is a diet analysis a reliable
predictor of caries.42
Salivary flow
Low salivary flow will limit the sup-
ply of calcium and phosphate ions
available for remineralization, and
reduce the clearance of food debris
and cariogenic bacteria from tooth
surfaces. The normal secretion rate of
stimulated saliva in healthy adults is
1-2 mL/mir~:~and a decreased flow
has been associated with caries in
older a d ~ l t s . * ~The
, ~ , *flow
~ of saliva
does not change with age, although
elders do consume large quantities of
medications with xerostomic side-
effects.29,45-47
The buffering capacity of saliva is
usually considered normal when the
pH is higher than 5.5,48and a lower
pH suggests that the risk of caries is
elevated. Indeed, the buffering capac-
ity of saliva has also been associated
specifically with the prevalence of
root but it is likely that the
association also extends to coronal
surfaces.
Distribution
The distribution of a disease influ-
ences the resources needed to diag-
nose, prevent, or treat it. In the USA
over the past 20 years, the mean
number of teeth for persons aged 65-
74 years has increased from 17%to
SCD Special Care in Dentistry, Vol 17 No 6 1997 197
19%, while the average number of
decayed and filled teeth increased
from 7.3 to 9.K50
Residents of LTC facilities com-
pared with individuals who live
independently appear more prone to
c a r i e ~ . ~Inl one
- ~ ~Canadian study, for
example, almost three-quarters of the
elderly institutionalized participants,
in contrast to about two-thirds of
those who lived independently,
over one year.31Similar caries inci-
dence rates have been reported by
which suggests that caries is
particularly rampant among a few
highly susceptible individual^.^^
Impact
Caries can produce pain, chewing
difficulties, and facial disfigurement,
while the replacement and restora-
tion of teeth place a considerable bio-
logical, sociological, and economic
burden on the individual and on soci-
ety as a whole. Caries is the primary
cause of tooth loss in all age
gr0ups,5~-~~ but it can be devastating
in old age, when large numbers of
teeth are extracted over a relatively
short period of time.60There is some
controversy about the significance of
losing molar however, there
is no doubt that the loss of anterior
teeth can have a profound impact on
appearance, speech, and overall well-
being.63-65
Caries is commonly associated
with pain, although elderly tooth
pulps are frequently protected from
noxious stimuli through demineral-
ized enamel and dentin by a lifetime
deposition of secondary dentin with-
in the pulp. The negative aspect of
this insulation from pulpal irritation
is that a slowly advancing lesion can
weaken the crown of a tooth without
symptoms to the point of fracture.
Consequently, frequent surveillance
is an essential part of health promo-
tion in old age to minimize tooth loss.
Management
’
There are several aspects to the man-
agement of caries, ranging from
dietary counseling to removal of a
severely infected tooth, although
dentists have focused largely on
restoration of damaged tooth struc-
ture. The decision to remineralize,
restore, or extract a tooth depends
upon the extent of the structural
damage.
Prevention
Preventive strategies should focus on
populations where the risk of caries
is particularly high.31,66,67
Numerous
strategies, most notably dietary con-
trol and oral hygiene along with
applications of remineralizing and
antimicrobial agents, have been used
successfully on high-risk children, so touring, and polishing the surface
with some modifications it is likely
that they will work on frail elders.
Dietary control
Control of food intake may be neither
feasible nor desirable for elderly
patients who are medically, socially,
or psychologically compromised.
Nevertheless, education of caregivers
about the association between caries
and the consumption of refined car-
bohydrates may help some of the res-
idents who are solely dependent on
caregivers for selection and intake of tooth surface if an individual cannot
meals and snacks.
Oral hygiene
Inadequate removal of bacterial
plaque is associated with the initia-
tion and progression of ~aries,6~*~O
and with the risk of caries in old
age.3l The physical and mental limi-
tations of old age superimposed on a
complex oral environment render
good hygiene difficult. Sudden
changes in physical, mental, and
social conditions can detract from the
individual’s ability and motivation to
clean the mouth.70Yet, despite these
difficulties, oral hygiene may be the
best way of controlling caries in this
age g r o ~ p .Indeed,
~ ~ , ~with
~ meticu-
lous hygiene and application of a
fluoridated toothpaste, it may be pos-
sible to remineralize root lesions.68As so this may be useful for patients
yet, however, the possibility of
improving oral hygiene in older age
groups with mental and physical dis-
198 SCD Special Care in Dentistry, Vol17 No 6 1997
abilities has been q ~ e s t i o n e d . ~ ~ , ” t ~ ~a fluoride varnish is being applied,
There is some evidence that electric
toothbrushes may help,75but the
complicated topography of heavily
restored and irregularly spaced teeth
is difficult to clean no matter what
instrument is used.
Remineralizingagents
Fluoride is the only chemical agent
available that is capable of remineral-
izing teeth and creating surface resis-
. ~ ~ ~ ~ ~ nonspecific anti-bacterial effecF8and
tance to d e m i n e r a l i ~ a t i o nThe
usual way to remineralize a shallow
or superficial lesion is to discourage
plaque retention by cleaning, recon-
before applying a fluoride rinse, gel,
or ~ a r n i s h . l ~ Fluoride
, ~ ~ - ~ l is available
in various formulations and can be
applied as a rinse, a gel, or a varnish
to the teeth,17,68,s2-84 and there is no
evidence that any one form has thera-
peutic superiority?
When the risk of caries is low, a
daily fluoride rinse with 15 mL of
0.05% sodium fluoride held in the
mouth for one minute after the last
meal of the day is useful. A tooth-
brush or a cotton-tipped applicator
can help to carry the fluoride to the
use a mouthrinse, but when the risk
of caries is high, a resilient vinyl tray
will help to deliver and hold the fluo-
ride, preferably a neutral 2% sodium
fluoride gel, on the teeth for a reason-
able period of time.
Acidulated fluoride gels are used
widely to enhance the chemical depo-
sition of the fluoride ion, but the
acidic composition can damage
ceramic dental restorations, which
may limit their use in this age group.
Stannous fluoride gels have an
antimicrobial action, although the
stannous ion may stain teeth and
dentures, and it may even have an
unpleasant taste.
Concentrated fluoride varnish
applied every 3-6 months to exposed
root surfaces decreases the develop-
ment of root caries ~ignificantly,8~.~~ Lactobacillus, and Candida albicans in
who cannot use rinses or gels reli-
ably. Unfortunately, for maximum
effect, teeth should be isolated when
and this task can be both difficult and
time-consuming, especially for
patients who are uncooperative.
Compliance with daily fluoride
applications is improved in LTC facil-
ities if it is prescribed in writing with-
in the resident’s medication orders as
part of the facility’s medical record.87
Antimicrobial medications
Although stannous fluoride has a
a bactericidal effect on mutans strep-
~ O C O C C U Schlorhexidine
,~~~~ is the
usual medication used to control
plaque organisms. Chlorhexidine is a
bisbiguanide salt that is lethal to
mutans streptoco~ci.~~ Chlorhexidine
reduces the amount of supragingival
plaque on the teeth,84,9z-95 and there is
evidence that it will inhibit the inci-
dence of caries when applied in var-
nish to exposed root surface^?^,^^
Daily use of a 0.2% chlorhexidine
gluconate rinse by young adults over
two years had no systemic or local
side-effects other than a bitter taste
and a yellow-brown surface stain on
the teeth.97-99Mutans streptococci do
not appear to develop resistance to
chlorhexidine, although Streptococcus
sanguis may become resistant to it
after some tirne.lo0Deactivation of
chlorhexidine by the surfactant sodi-
um lauryl sulfate in toothpaste has
been reported, but this can be avoid-
ed by allowing at least 30 minutes
between toothbrushing and the
application of chlorhexidine.lO’
A broadly based review of the lit-
erature found that chlorhexidine will
reduce the incidence of caries by
almost half.95In particular, a 1%
chlorhexidine gel applied daily in
custom trays for five minutes over
two weeks has reduced the incidence
of caries for institutionalized
elders.lo2There is evidence also that a
0.12% chlorhexidine rinse used either
daily or weekly for six weeks can
reduce mutans streptococcus,
the saliva of older adult^.^^,^^^
Recent investigations strongly
suggest that combinations of
chlorhexidine and fluoride may offer
even greater effectiveness than either
medication alone in reducing the
numbers of mutans streptococci104
and the incidence of c a r i e ~ . ' ~It~isJ ~ ~
not certain, however, that this regi-
men can be applied successfully for a
prolonged period by patients who are
disabled or very dependent on others
for hygiene and other mouth care.
Restorative interventions
Conservative debridement and
recontouring of shallow caries lesions
are reasonable alternatives to intra-
coronal restorations. The purpose of
the debridement and recontouring is
to produce a surface that can be
cleaned easily and remineralized to
resist further i n f e c t i ~ n . ' ~How-
~J~~
ever, large lesions in teeth with suffi-
cient structural integrity of the sup-
porting dentin can be restored with
(1)amalgam, (2) composite resin, or
(3) glass ionomer.
Amalgam
Amalgam fillings have been used
successfully to restore teeth for a very
long time, and their physical proper-
ties, handling characteristics, and low
cost make them especially suitable
for large lesions in poorly accessible
areas or where the restoration is sub-
jected to a heavy load.'@ Corrosion at
the amalgam-tooth interface also pro-
duces an excellent seal against bacter-
ial invasion.110Nonetheless, the diffi-
culty of creating undercuts and per-
forming adequate condensation lim-
its the usefulness of amalgam in root
surfaces.
Composite resin
Small accessible coronal cavities in
aesthetic zones are filled most effec-
tively with composite resins. The resin
will bond to an etched enamel or
dentinal surface, which probably
helps to resist further demineraliza-
tion of the tooth.ll' These filling mate-
rials are very sensitive to application
techniques, they are expensive, and
they wear more rapidly than amal-
gam, which limits their use to regions
where the restoration is highly visible.
Glass ionomer
Glass ionomer is promoted widely as
an ideal restorative material for root
cavities because it can adhere to
dentin and it contains f l ~ 0 r i d e .The
l~
adherence to dentin allows the mater-
ial to be applied directly to the cavity
with minimal preparation for
mechanicahetention, while the fluo-
ride is released at a high level during
the first few days, and at a low level
for up to G o years thereafter.""l14
The material is very soluble in saliva
for about 24 hrs until it is fully hard-
ened, so it must be protected by a
varnish during this critical period. In
addition, the adhesive properties, the
strength, and the pH of the glass
ionomer are sensitive to the tech-
nique used to prepare the dentinal
surface and to the powder/liquid
ratio of the mixture. These character-
istics may pose serious limitations on
the use of this material on root sur-
faces when the clinical environment
is impossible to control fully.
Recently, an "Atraumatic Restora-
tive Treatment (ART)" technique has
been suggested for removing caries
from teeth before restoring the sur-
face with a glass-ionomer material.l15
Indeed, it may not be necessary to
remove all of the infected dentin if a
secure seal can be achieved between
the external surface of the tooth and
the filling materia1.ll6Nonetheless, it
is necessary to isolate the lesion from
contamination with saliva or blood
before placing a glass-ionomer resto-
ration into a cavity, and to supple-
ment the restoration with a preven-
tive regimen to inhibit further devel-
opment and progression of caries.
The hybrid glass-ionomer and
composite resin (compomer) materi-
als are easier to handle than the glass
ionomer alone, and they are more
resistant to saliva. However, they
have not been tested adequately in
the Silver-reinforced
glass-ionomer materials have also
been developed to improve on the
physical properties of the conven-
tional glass ionomer. Unfortunately,
they release less fluoride, and they do
not bond as strongly to dentin.lZ0
Therefore, they offer no particular
advantage over conventional glass-
SCD Special Care in Dentlstry, Vol17 No 6 1997 199
ionomer or compomer materials.
Conclusion
The pathogenesis, measurement, dis-
tribution, impact, and management
of dental caries in chronically dis-
abled elders provide many biological
and physical uncertainties. It is a dif-
ficult infection to diagnose because of
the complicated dental environment
in elderly mouths. The relative insen-
sitivity of old teeth compounded by
an apparent unawareness of oral
hygiene may allow a lesion to weak-
en a tooth before the extent of the
problem is recognized. Consequently,
within a relatively short time, caries
can wreak havoc and impose a very
severe biological and economic bur-
den. Decisions to remineralize,
restore, or extract teeth depend large-
ly upon the extent of the structural
damage that the infection has caused.
The bacteria can be controlled with
microbial agents, such as fluoride
and chlorhexidine. Small demineral-
ized lesions can be remineralized
with fluoride, whereas the repair of
lesions that are cavitated can range
from direct debridement to compli-
cated restorations and prosthodon-
tics. Subsequent to elimination of the
infected lesions and restoration of the
dentition, the risk of future infection
should be assessed by monitoring the
flow, buffering capacity, and micro-
flora of the saliva. Long-term control
is achieved by careful surveillance of
the mouth and diet, and by regular
use of fluoride to enhance the re-
mineralizing capacity of saliva. Yet,
despite our ability to control this dis-
ease, it continues to be a rampant and
particularly distressing affliction in
old age.
Dr. Wyatt is an Assistant Professor, Faculty of
Dentistry, University of British Columbia, 2199
Wesbrook Mall, Vancouver, BC, Canada V6T
123. Dr. MacEntee is a Professor at LJBC.
Correspondence should be addressed to Dr.
Wyatt.
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