Oral health problems in Geriatric people

The mouth is referred to as a mirror of overall health, reinforcing that oral health

is an integral part of general health. In the geriatric population poor oral health has been

considered a risk factor for general health problems 12. Globally, poor oral health among

geriatric people has particularly been observed in the forms of high level of tooth loss,

dental caries experience, and high prevalence rates of periodontal disease, xerostomia,

and oral precancerous /cancerous lesions. The negative impact of poor oral conditions on

daily life is particularly significant among edentulous people. Extensive tooth loss

reduces chewing performance and affects food choice; for example, edentulous people

tend to avoid dietary fibre and prefer foods rich in saturated fats and cholesterols.

Edentulous condition is also shown to be an independent risk factor for weight loss and,

in addition to the problems related to communication. Moreover, poor oral health and

poor general health are interrelated, primarily because of common risk factors; for

example, severe periodontal disease is often associated with diabetes mellitus, ischemic

heart disease and chronic respiratory disease. Tooth loss has also been linked with

increased risk of ischemic stroke and poor mental health 8.

CORONAL DENTAL CARIES AND ROOT SURFACE CARIES

Most common among oral diseases is dental caries. Dental caries is a multi-

factorial disease of the teeth that results in localized dissolution and destruction of the

calcified tissue. Dissolution progresses to cavitation and if untreated, to bacterial invasion

of the dental pulp, whereby oral bacteria access the bloodstream. Mostly elderly patients

are prone to root caries due to receding gums leading to exposure of root surface. Use of

medication decreases salivary flow and leads to dry mouth. Systemic health conditions

11
 Oral health problems in Geriatric people

hinder them from maintaining a proper oral hygiene. It is likely that older adults are at

greater risk of oral diseases because their possible disability might affect their ability to

maintain good oral hygiene and restrict their access to necessary dental care 13. The

prevalence of caries in elderly people varies between 20–60% in the community and 60–

80% in care homes. There is increasing evidence that elderly people may experience

rampant caries, often developing in relatively short time period. The major predisposing

conditions for caries development in elderly people are: impaired cognitive and

functional ability, medication-induced hyposalivation, reduced saliva buffer capacity and

high saliva acidity, diabetes mellitus, the number of exposed root surfaces due to gingival

recession, poor oral hygiene, high frequency of sugar consumption, and poor socio-

economic conditions7.

Root surface caries result from an age-related condition that develops on

cementum following gingival recession (Figure-1) or as an extension of existing coronal

caries onto the root surface. Both new and recurrent root surface caries develop at the

same rate. Since cementum is less mineralized than enamel, it is more susceptible to

decay. These lesions appear as well-defined and discoloured defects on cementum or at

the cementum-enamel junction (Figure-2). The prevalence of untreated root surface

caries has been reported as 22% in an older population, with an increased incidence in

residents of facilities for long-term care. Individuals who have multiple medical

conditions, who are taking numerous medications, and who are undergoing medical

procedures are at risk. Other factors that predispose elderly individuals to root surface

caries are a poor diet (with frequent sugar consumption), salivary gland hypo function,

12
 Oral health problems in Geriatric people

insufficient fluoride exposure, gingival recession, oral-facial motor deficits, poor oral

hygiene, and decreased access to regular dental treatment. A recent study also

demonstrated that the presence of removable partial dentures is an independent risk factor

for developing root surface caries in older adults. Root surface caries are a diagnostic and

restorative challenge since they are frequently located on interproximal surfaces, may not

be visible by intraoral radiography, and can extend into sub gingival regions9.

Coronal caries are also quite prevalent among older persons, and the risk

factors are similar to those for root surface caries (with the exception of gingival

recession). These enamel lesions present clinically as discolored defects on occlusal

and/or proximal tooth surfaces and range from soft to rubbery in texture. Although

rapidly progressing decay is soft and can be painful, slowly developing long-standing

lesions are typically harder (from remineralisation) and are asymptomatic. As a tooth

ages, deposition of secondary and reparative dentin occurs, which can aid in increasing

caries resistance and in decreasing dental sensitivity. A lifelong history of dental

restorations places the older person at risk for developing recurrent coronal decay. Of the

reported cases of coronal caries in one study of geriatric patients, 86% were recurrent

lesions. Another study found that 31% of dentate individuals over the age of 70 years had

clinically untreated coronal caries. Decay developing around existing restorations is

difficult to detect and more challenging to restore9.

Common Causes:

• Poor or lack of tooth brushing with fluoride toothpaste

• Lack of cleaning between teeth

13
 Oral health problems in Geriatric people

• Snacking on foods high in sugar

• Frequent intake of sweetened drinks, including fruit juices and fizzy drinks

• Dry mouth

Warning Signs:

• Tooth covered in food and debris

• Holes in teeth

• Broken teeth

• Brown or discoloured teeth

• Tooth sensitivity to hot or cold foods

• Difficulty with eating or chewing

• Toothache

• Bad breath

• Swelling in the face and jaw area

How to Prevent:

• Brushing twice daily with fluoride toothpaste

• Reduction of sweetened foods and drinks, especially in between meals – and replacing

with “tooth safe” alternatives such as water rather than juices or fizzy drinks

• Regular professional check-ups and cleaning

PERIODONTAL DISEASE

Periodontal disease is an inflammatory disease caused by gram-

negative anaerobic bacteria from dental plaque displaying virulent properties and

increasing pro-inflammatory cytokines. Periodontal disease progresses to periodontitis

14
 Oral health problems in Geriatric people

when the inflammation extends to the periodontal ligament and alveolar bone which lead

to loss or recession of gingival tissue, decrease in alveolar bone mass, tooth

mobility/tooth loss, and potentially edentulism. These pro-inflammatory cytokines,

notably tumour necrosis factor (TNF), interleukin-1 beta (IL-1β), and interleukin-6 (IL-

6), associated with periodontal disease are noteworthy because they also have

associations with many other chronic inflammatory diseases such as rheumatoid arthritis,

osteoporosis, myeloma, type II diabetes and atherosclerosis; all of these diseases and

conditions have been traced back to the same or similar etiologic onset of the

inflammation. Further, Actinobacillus actinomycetemcomitans, Porphyromonas

gingivalis and other bacteria originating from plaque in the oral cavity can travel to other

areas of the body and have been linked to infections of the endocardium, meninges,

mediastinum, vertebrae, hepatobiliary system, lungs, urinary tract, and prosthetic joints.

Plaque bacteria have been associated with systemic implications in the cardiovascular and

nervous systems8.

Medications and medical problems that are common among older

adults have an adverse effect on periodontal health. For example, gingival hyperplasia

has been associated with the use of phenytoin, cyclosporine, and calcium channel

blockers. Diabetes, even when well controlled, is associated with rapid periodontal

breakdown due to impaired leukocyte function, altered collagen metabolism, and

microvascular changes. Oral mucocutaneous diseases such as erosive lichen planus and

cicatricial pemphigoid will produce desquamative gingivitis9.

15
 Oral health problems in Geriatric people

Common Causes:

• Inadequate or lack of tooth brushing

• Lack of cleaning between teeth

• Untreated gingivitis

Warning signs:

• Red, swollen or tender gums

• Receding gums or gums that pull away from the teeth

• Loose teeth

• Pus between the gum and the tooth

 Bad breath

• Change in the way teeth fit together when biting

• Change in the fit of partial dentures

How to Prevent:

• Brushing twice daily with fluoride toothpaste

• Reduction of sweetened foods and drinks, especially in between meals – and replacing

with “tooth safe” alternatives such as water rather than juices or fizzy drinks

• Regular professional check-ups and cleaning

TOOTH WEAR

Abrasion

Dental abrasion is the pathologic wearing of teeth as a result of abnormal

processes, habit, or abrasive substance14.

16
 Oral health problems in Geriatric people

Etiology:

1. Pipe smoking

2. Nut and seed cracking

3. Nail biting

4. Hairpin biting

5. Occupational (Musicians, tailors, carpenters, cobblers)

6. Toothbrush, toothpaste

Attrition

Dental attrition is defined as the physiologic wearing of teeth resulting

from tooth to tooth contact as in mastication15. This is an age-related process that can

occur at the incisal or occlusal surfaces and sometimes on the proximal surfaces.

Common causes:

 Abrasives of diet

 Parafunctional habits

 Occlusal interferences

ORAL PRECANCER & ORAL CANCER

Age-specific rates for cancer of the oral cavity increase

progressively with age, most cases occurring in the groups above 60 years. Oral cancer is

more common in populations of less developed than developed countries 16. In India, with

its population of over one billion people, people older than 60 years constitute 7.6% of

the total population, which amounts to 76 million. Incidence of oral cancer, which is an

old age disease, is highest in India 8. The prevalence of leukoplakia and lichen planus in

17
 Oral health problems in Geriatric people

older people ranges from 1.0 to 4.8% and 1.1 to 6.6%, respectively. Leukoplakia is more

frequent among men while lichen planus is associated with the female gender. Tobacco

use is the most important determinant of oral cancer and premalignant lesions including

leukoplakia, but heavy consumption of alcohol is also a significant factor in relation to

these conditions. Socio-economic status such as low levels of education and income is a

risk factor for leukoplakia. In contrast, high fruit and vegetable intake are protective

factors because of the high content of carotenoids and vitamin C16.

Common Causes:

• Tobacco use

• High levels of alcohol consumption

• Infection with viruses such as HPV

Warning Signs:

• An ulcer or sore spot in the mouth that does not heal within two weeks

• A white or red patch in the mouth

• Difficulty eating or swallowing

• Swelling of the jaws

• A lump in the throat

• Difficulty wearing dentures

How to Prevent/Manage:

• Quit smoking

• Reduce the intake of alcohol

• Eat a healthy balanced nutritious diet

• Regular oral examination by a dentist

18
 Oral health problems in Geriatric people

TOOTH LOSS

A functional dentition plays an essential role in mastication, deglutition,

phonation, facial aesthetics and expression. The loss of all teeth was considered a normal

part of aging and there is increased retention of natural dentition by older adults, is

increasing by using with or without dentures. Tooth loss is directly linked to dental caries

and periodontal disease but may also be related to systemic conditions such as

osteoporosis and diabetes mellitus. Edentulous adults, even those with removable

prostheses, have decreased masticatory forces and impaired chewing efficiency.

Diminished oral motor function can induce masticatory muscle atrophy and deterioration

of muscle contractile properties, further inhibiting chewing capability. Rapid alveolar

bone resorption follows tooth loss and continues throughout life. In severe cases, alveolar

ridge atrophy, especially in the mandible, can lead to significant problems in denture

fabrication and retention and possibly to mandibular fracture. Furthermore, poorly fitting

prostheses can accelerate the loss of alveolar bone9.

XEROSTOMIA

Dry mouth is a common complaint in older people and the condition is reported in

approximately 30% of the population aged 65 and older. Persons suffering from dryness

of the mouth are likely to experience severe oral problems, including high levels of dental

caries, in addition to difficulties in chewing, eating and communicating. A reduced

unstimulated salivary flow and subjective oral dryness are significantly associated with

age and the female gender.

19
 Oral health problems in Geriatric people

Drug-induced xerostomia is most common in old age because high proportions of

older adults take at least one medication that causes salivary dysfunction. The drugs

mostly responsible for dry mouth are tricyclic antidepressants, antipsychotics, atropinics,

beta blockers and antihistamines, thus the complaint of dry mouth is particularly frequent

in patients treated for hypertension, psychiatric or urinary problems. Smoking is another

important risk factor of dry mouth16.

Common Causes:

• Certain medications like tricyclic antidepressants, antipsychotics, atropinics, beta

blockers and antihistamines

• Radiation and chemotherapy

• Conditions such as Sjogren’s syndrome and Alzheimer’s disease

Warning signs:

• Difficulty in swallowing and speaking

• Dryness in the mouth

• Burning sensation or sore feeling in the mouth

• Bad breath

How to Prevent/Manage:

• Follow strict daily oral hygiene routine using soft brush with fluoride toothpaste and

cleaning between teeth.

• Salt and Bicarbonate (baking soda) rinses can be used as often as required during the

day to remove any mucus or debris from the mouth.

• Discuss the medications with the doctor to find suitable alternatives that are less likely

to cause dry mouth.

20
 Oral health problems in Geriatric people

• Drink plenty of water to avoid dehydration

• Avoid drinking sweetened drinks, especially in between meals

• Special products are available in the market like artificial saliva to restore moisture in

the mouth.

DENTURE RELATED CONDITIONS

Denture stomatitis is a common oral mucosal lesion of clinical importance in old-

age populations. The prevalence rate of stomatitis is reported within the range of 11–67%

in complete denture wearers. In many cases of denture stomatitis, colonization of yeast to

the fitting surface of the prosthesis is observed. Other factors of stomatitis include

allergic reaction to the denture base material or manifestations of systemic disease 16.

The prevalence of denture stomatitis correlates strongly to denture hygiene or the

amount of denture plaque. Usage of denture at night, neglect of denture soaking at night

and use of defective and unsuitable dentures are also risk factors for denture stomatitis, as

is tobacco and alcohol consumption. Other major denture-related lesions include denture

hyperplasia and traumatic ulcer. Denture hyperplasia is particularly frequent in persons

with ill-fitting and/or unretensive dentures. Both lesions have been observed more often

among complete denture wearers than in persons wearing removable partial dentures16.

Common Causes:

• A weak immune system which can be associated with the frail older people

• Leaving dentures in the mouth for a long time without adequate cleaning

• Dry mouth

21
 Oral health problems in Geriatric people

• Taking antibiotics for a long time

Warning Signs:

• White patches that cannot be wiped away

• Small red inflamed dots on the tongue

• Inflamed or redness of palate (roof of the mouth)

How to Prevent/Manage:

• Eating a well-balanced nutritious diet, especially important in the frail older people

• Allow the gum tissue to rest from wearing dentures. Take dentures out of the mouth

overnight, clean and soak in a glass of water with a cleaner such as Steradent or Polident

• Use of anti-fungal medications

MEDICATION AND ORAL HEALTH

A major impact of systemic diseases on the oral health of older adults is caused

by the side effects of medications. With increasing age and associated chronic disease,

the elderly are prescribed an ever-expanding variety of medications. Besides the desired

therapeutic outcome, adverse side effects may alter the integrity of the oral mucosa.

Problems such as xerostomia (dry mouth), bleeding disorders of the tissues, lichenoid

reactions (oral tissue changes), tissue overgrowth, and hypersensitivity reactions may

occur as a result of drug therapy.17

22
 Oral health problems in Geriatric people

Table-1 Overview of oral problems caused by medications17

23
Oral health problems in Geriatric people

24
 Oral health problems in Geriatric people

ORAL HEALTH AND ITS IMPACT ON GENERAL HEALTH

Oral health influences mastication, food selection, weight, speech, taste,

hydration, appearance, and psychosocial behaviour and is therefore an essential part of

general health with an impact on a person’s quality of life during his/her entire lifespan.

Several worldwide reports have shown that the oral health of elderly people, in particular

that of frail and disabled elderly people, is rather poor. Associations have been reported

between oral health and general health, for instance with respect to diabetes mellitus,

respiratory diseases and cardiovascular diseases. In addition, various studies have

suggested that between 50% and 75% of care home residents have some difficulty in

swallowing, and as a consequence have a high risk of choking and developing aspiration

pneumonia from anaerobic bacteria that are present in the mouth10.

25