November/December 2014

Oral Health Care Affects Quality of Life
By Ira B. Lamster, DDS, MMSc; and Kavita P. Ahluwalia, DDS, MPH
Today's Geriatric Medicine
Vol. 7 No. 6 P. 22

The association between oral infection and systemic disease warrants particular vigilance in monitoring older adults' oral health.

Oral diseases and their sequelae, which are intimately associated with nutrition, quality of life, and healthy aging, can be effectively managed by regular self-care and professional dental care. But older adults, especially community-dwelling older adults, face numerous challenges to receiving professional oral health services and often have difficulty with the performance of personal daily oral care.

The oral cavity is anatomically complex and represents the point of entry of food and liquid into the body. Key structures include the dentition (32 teeth in the permanent dentition), the periodontal tissues (including the alveolar bone and soft tissues supporting the dentition), the tongue, and the oral mucosa, which lines the cavity and includes the minor salivary glands, and orifices of the major glands. Contiguous structures include the temporomandibular joints, salivary glands, oropharynx, and muscles of mastication.

Cognitive, functional, and medical declines, coupled with a workforce with limited training to deal with these complex problems, constitute primary challenges to providing oral health services. The increasing diversity of older adults in the United States further confounds the picture; health-related practices and perceived need for services are informed by culture and social norms in older adults and their caregivers. Given the multifactorial nature of the challenges faced by older adults, a multidisciplinary approach that includes dental and nondental providers is required to manage the oral health care needs of older adults.

Dental Changes
Changes in the oral cavity associated with age include moderate tooth wear, 2-3 mm of loss of periodontal support for the dentition (which is often associated with gingival recession on the buccal surfaces of the teeth, exposing a few millimeters of the anatomical root), some drifting of teeth, thinning of the oral mucosa, and the reduction in chewing efficiency due to weakened muscles of mastication. These changes should be observed over time by an oral health care professional but generally require no treatment unless symptomatic. Further, relatively simple preventive strategies should be considered, including the use of toothpastes and gels with a higher concentration of fluoride to prevent recurrent dental and root caries, and the use of a powered toothbrush if manual dexterity is compromised.

Other changes that occur in the oral cavity are pathologic and require active intervention. Periodontal disease is cumulative, and older individuals demonstrate the highest prevalence of disease.1 As support for the dentition is reduced with loss of the crestal alveolar bone, the teeth become compromised. This is associated with gingival inflammation and eventually tooth drifting and loosening, and periodontal abscess formation. Periodontal therapy, which generally begins with nonsurgical debridement procedures, would be required to halt disease progression. Systemic or locally delivered antibiotics are sometimes needed. Exposure of the anatomical roots of teeth associated with gingival recession can lead to the development of dental caries on root surfaces. This is often exacerbated by reduced salivary flow, which is a side effect of many medications used in the treatment of chronic diseases common in older adults.2

Untreated periodontal disease and advanced caries lead to tooth loss. It is important to emphasize that tooth loss is not an inevitable consequence of aging. The trend in the past few decades has been a reduction in tooth extractions and a lower prevalence of complete edentulism. This is likely the result of messaging about prevention, use of fluoride, increased awareness of oral health, and the recognition that tooth retention is important for healthful aging. Despite a decline in edentulism in the United States, the prevalence of total tooth loss in the elderly remains high3; nationally, approximately 25% of adults over the age of 60 are edentulous, and elders with teeth are missing, on average, 50% of their teeth.4

Increased tooth retention later in life will create a greater need for dental services. In addition, even if a person is edentulous and has complete dentures, regular dental care is required to assess the adequacy of the removable prosthetics and to check for salivary flow and for the development of benign, premalignant, or malignant mucosal lesions.

Oral Disease
Oral squamous cell carcinoma is the most serious disease of the oral cavity, with some 30,000 new cases developing per year, and resulting in 8,000 deaths per year. The mean age at diagnosis is 62, with a higher prevalence in black males. Cigarette smoking and excessive alcohol consumption are the most important risk factors in these groups. The five-year survival rate has hovered at about 50% for decades.5 Early diagnosis remains essential to increase the chances of a cure. Nondental providers, especially geriatricians and family physicians, can play an important role in early detection of oral cancer through risk and symptom detection, risk reduction, and examination of the oral cavity. Other oral findings in older adults that may result in pain and difficulty eating are blistering diseases, including pemphigus vulgaris and pemphigoid.

Oral Infection/Inflammation and Systemic Diseases
Over the past 20 years, a large body of evidence has suggested that oral infection and inflammation (associated with periodontal disease, but possibly related to acute endodontic problems) are associated with the progression of certain chronic disorders affecting the elderly, and in particular diabetes mellitus and cardiovascular disease. Recent data suggest that periodontitis is a risk factor for other disorders, including chronic kidney disease, respiratory diseases, and dementia.

The mechanisms and biologic plausibility are related to the systemic effects of both oral infection and oral inflammation. Periodontal disease is initiated by Gram-negative anaerobic organisms in the gingival sulcus, which can gain entry to the circulation as a result of ulceration of the epithelium within the periodontal pocket.

These microorganisms or their components can then seed distant tissues and induce an inflammatory response. Further, the host response in the periodontal tissues is characterized by the influx of inflammatory cells (macrophages and neutrophils) and activation of resident cells such as endothelial cells and fibroblasts, which produce an array of proinflammatory mediators (including TNF-α, IL-6, and IL-1β), which gain access to the systemic circulation and induce an inflammatory reaction.

The association between diabetes and periodontal disease perhaps best illustrates these interactions. The data relating diabetes mellitus and periodontitis are robust.6

The severity of periodontitis is linked to poor metabolic control, with poor control being associated with increased prevalence of periodontitis. Conversely, treatment of periodontitis in patients with diabetes, in the absence of any other treatment, has been shown to reduce HbA1c by 0.3% to 0.4%. Further, the presence of periodontitis in a patient with diabetes places the individual at greater risk of developing chronic kidney disease, including macroalbuminuria and end-stage renal disease, as well as increasing the risk of death from cardiorenal causes.6

A broad range of studies including animal models, intervention trials examining surrogate markers of risk for cardiovascular disease, and analysis of large epidemiologic databases, indicates that periodontal disease is associated with increased risk of cardiovascular disease.7 Periodontal microorganisms have been detected in coronary atheromas, and periodontal lesions contribute to the systemic inflammatory burden, as measured by circulating levels of proinflammatory cytokines.

Other relationships are not as well defined but have begun to be explored. In particular, the link between periodontitis and an increased risk of respiratory diseases is clinically important. The periodontal infection/inflammation-respiratory disease association is more direct and includes aspiration of bacteria into the bronchial tree, as well as the concept that an increased level of bacterial and host enzyme activity in saliva, which is seen when periodontitis is present, would expose binding sites for respiratory pathogens and increase the risk of respiratory disease, including influenza.8

Oral Disease/Dysfunction and Quality of Life
Oral health is central to nutrition and socialization, two of the primary hallmarks of successful aging. Untreated oral disease and loss of oral function can result in pain and difficulty chewing, swallowing, and eating, which may result in food avoidance and/or modification and, eventually, nutritional inadequacy. Even in cases where missing teeth are replaced by dentures or bridges, older adults report difficulty eating and chewing, avoidance of fruits and vegetables, and poor tolerance of grains. Food avoidance and modification may result in weight loss, resulting in ill-fitting dentures, which may lead to pain and discomfort, and further difficulty eating, speaking, and socializing.9

Older adults are at high risk of dental diseases because of medical, functional, and cognitive comorbidities that may compromise oral health and make proper daily oral care challenging and utilization of professional oral health services difficult. In addition to increasing the risk of dental and root caries, xerostomia may result in painful speech and difficulty chewing and swallowing,10 impacting nutrition and social interactions.

The sequelae of oral cancer include pain, loss of function, and often disfiguring impairment and death; problems accessing dental care often preclude early detection. It is therefore imperative that those at risk, older adults and tobacco users, receive primary and secondary prevention from dental and nondental professionals at regular intervals.

Utilization of Oral Health Care
Although gains in dentate status represent an improvement in oral health and health care across the lifespan, tooth retention remains a challenge. As the proportion of older adults retaining teeth grows, so too does the prevalence of oral diseases in this segment of the population, along with the need to access and utilize dental services. Despite the significant negative impact of oral diseases on quality of life, utilization of professional dental services by the elderly remains low.11

Suggested reasons include a lack of insurance, the cost of care, patients' functional and cognitive limitations, misinformation about oral health and health care, transportation problems, fear, a perceived low need and demand for services, and a perception that dental services are not needed if a patient is edentulous. Edentulous elderly report lower perceived need and rates of utilization than dentate elderly;11 individuals who have no teeth believe they do not need to seek dental services, regardless of the quality and functional adequacy of dental prostheses or impact on their quality of life.

Oral Disease Risk, Symptoms, and Management
While primary responsibility for management of the oral cavity is and should remain with the dental team, there is a role that nondental providers can and should play to ensure that older adults have healthy mouths and any negative impact on patients' quality of life and function is minimal. In this respect, it is important for nondental providers to be aware of signs and symptoms that may be associated with oral disease and dysfunction and require further investigation and/or referral to a dentist. Risk factors, signs, and symptoms that should signal cause for concern among nondental providers include the following:

• Pain and infection: Pain can occur in the teeth or the oral soft tissues. Weight loss, observation of wincing while eating, pain while eating or drinking hot or cold foods, changes in taste, and unexplained oral malodor should be investigated. In dentate older adults, dental caries, dental and periodontal abscesses, loose teeth, and lesions related to partial dentures should be considered. For the edentulous patient, denture-related irritation may be important. For all older adults, mucosal lesions should be thoroughly investigated.

• Diet and nutrition: Oral disease, dysfunction, pain, and ill-fitting dentures often result in a poor diet that is low in fruits, vegetables, and proteins and rich in processed carbohydrates. In many cases, foods are modified with fruits peeled and puréed and vegetables cooked until soft, altering their nutritional content. Older adults with dental and oral problems usually prefer processed grains and rice because they are easier to chew. Any change in diet should prompt an investigation of oral problems; conversely, dietary needs and nutritional counseling should be considered in older adults with missing teeth and/or dentures.

• Dry mouth: A side effect of many medications used to manage chronic diseases is dry mouth, which increases the risk of dental caries involving the crowns or roots of teeth. Xerostomia makes talking and swallowing difficult in both dentate and edentulous older adults. Older adults suffering from chronic diseases such as diabetes, hypertension, and cardiovascular disease should be counseled to manage dry mouth, initially with frequent sipping of water and sugar-free hard candy or gum. If the problem persists, other approaches include referral to an oral health care provider and/or a change in medications.

• Tobacco use: Tobacco use is a risk factor for both periodontal disease (in dentate older adults) and oral cancer. Tobacco users should be counseled to quit and referred to a dentist for regular examination and management of tobacco-related oral lesions.

• Functional and cognitive declines: Functional and cognitive declines may result in difficulty performing daily oral care. Arthritis can hinder the ability to hold a toothbrush/denture brush or manipulate dental floss, and contribute to difficulty walking to the sink or standing, which can make brushing, flossing, and denture cleaning problematic. Instruct caregivers to help or assist with daily oral care in these cases.

Challenges to Providing Oral Health Care
A number of challenges are associated with providing oral health care services to older adults, the first of which is reimbursement. In the United States, traditional Medicare provides no routine dental benefits (some Medicare Advantage plans do cover dental services). While routine preventive dental care is more affordable, advanced therapies to replace missing teeth are expensive. The irony is that newer treatments, including dental implants, now offer very effective options for patients who are partially or completely edentulous. In a few states, such as New York, the Medicaid program provides adult benefits, but these exclude the more advanced and complex procedures. Lastly, while health care reform in the United States addresses dental benefits for children and adolescents, that is not the case for adults.12,13

Another challenge to providing oral health care to older adults is the lack of a recognized dental specialty in geriatrics (ie, geriatric dentistry). While it is expected that general dentists will care for the majority of older adults, there is a scarcity of specifically trained practitioners with expertise in providing dental services to the medically complex older patient. There are a limited number of dentists with special training who have received such training in geriatric fellowship programs. As the population ages and more people are living into their eighth and ninth decades, this problem will become more acute.

The key lies in establishing interprofessional relationships that promote comprehensive management of older patients. Further, there are a number of important new initiatives that have focused attention on the oral health care needs of older adults.14,15 An appreciation of the importance of oral health to successful aging and promotion of community living requires interprofessional cooperation involving oral health care providers, medical providers, social workers, home care workers, and families.

— Ira B. Lamster, DDS, MMSc, served as dean of the Columbia University College of Dental Medicine from 2001 to 2012 and senior vice president of Columbia University Medical Center from 2006 to 2012. Currently Dean Emeritus at the Columbia University College of Dental Medicine and a professor in the department of health policy and management in the Mailman School of Public Health, he is the author of more than 180 manuscripts and book chapters. He is the American Dental Association's representative to the Science Committee of the FDI World Dental Federation.

— Kavita P. Ahluwalia, DDS, MPH, is an associate professor of clinical dental medicine at Columbia University College of Dental Medicine. Working with communities to address oral health and oral health care disparities among older adults, she is active in addressing oral health among institutionalized elderly, focusing on collaboration with local and regional organizations to address programmatic and policy concerns in this population.

References
1. Eke PI, Dye BA, Wei L, Thornton-Evans GO, Genco RJ, CDC Periodontal Disease Surveillance workgroup: Beck J, Douglass G, Page R. Prevalence of periodontitis in adults in the United States: 2009 and 2010. J Dent Res. 2012;91(10):914-920.

2. Moore PA, Guggenheimer J. Medication-induced hyposalivation: etiology, diagnosis, and treatment. Compend Contin Educ Dent. 2008;29(1):50-55.

3. QuickStats: prevalence of complete tooth loss among older adults, by age group and federal poverty level (FPL) — National Health and Nutrition Examination Survey, 1988-1994 and 1999-2004. Centers for Disease Control and Prevention website. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5632a6.htm. Updated August 16, 2007. Accessed August 4, 2014.

4. Oral health for older Americans. Centers for Disease Control and Prevention website. http://www.cdc.gov/oralhealth/publications/factsheets/adult_oral_health/adult_older.htm. Updated July 10, 2013. Accessed August 4, 2014.

5. SEER stat fact sheets: oral cavity and pharynx cancer. National Cancer Institute website. http://seer.cancer.gov/statfacts/html/oralcav.html. Accessed August 4, 2014.

6. Chapple IL, Genco R, working group 2 of the joint EFP/AAP workgroup. Diabetes and periodontal diseases: consensus report of the Joint EFP/AAP Workshop on Periodontitis and Systemic Diseases. J Periodontol. 2013;84(4 Suppl):S106-S112.

7. Tonetti MS, Van Dyke TE, working group 1 of the joint EFP/AAP workgroup. Periodontitis and atherosclerotic cardiovascular disease: consensus report of the Joint EFP/AAP Workshop on Periodontitis and Systemic Diseases. J Periodontol. 2013;84(4 Suppl):S24-S29.

8. Abe S, Ishihara K, Adachi M, Sasaki H, Tanaka K, Okuda K. Professional oral care reduces influenza infection in elderly. Arch Gerontol Geriatr. 2006;43(2):157-164.

9. Gil-Montoya JA, Subira C, Ramon JM, Gonzalez-Moles MA. Oral health-related quality of life and nutritional status. J Public Health Dent. 2008;68(2):88-93.

10. Cassolato SF, Turnbull RS. Xerostomia: clinical aspects and treatment. Gerodontology. 2003;20(2):64-77.

11. Dolan TA, Atchison K, Huynh TN. Access to dental care among older adults in the United States. J Dent Educ. 2005;69(9):961-974.

12. Jones JA. Financing and reimbursement of elders' oral health care: lessons from the present, opportunities for the future. J Dent Educ. 2005;69(9):1022-1031.

13. Edelstein BL, Samad F, Mullin L, Booth M. Oral health provisions in U.S. health care reform. J Am Dent Assoc. 2010;141(12):1471-1479.

14. Marshall S, Northridge ME, De La Cruz LD, Vaughan RD, O'Neil-Dunne J, Lamster IB. ElderSmile: a comprehensive approach to improving oral health for seniors. Am J Public Health. 2009;99(4):595-599.

15. Marshall SE, Cheng B, Northridge ME, Kunzel C, Huang C, Lamster IB. Integrating oral and general health screening at senior centers for minority elders. Am J Public Health. 2013;103(6):1022-1025.