Getting long in the tooth! An ageing population & Oral Health
Promotional FeaturesPosted by: manpreet.boora 25th October 2017
Advances in medical research and treatment of disease has increased life expectancy, on average people may live up to thirty years longer than previous generations1,2,4,5. There are 65 million people living in the UK, 17% are over the age of 65 with predictions of a rise in that figure to 23% by 20331,2. The generation known as ‘baby boomers’ (people born 1946 – 1964) and are now entering or already well into old age.
An ageing population (defined as over 65 years and above) brings new challenges to the provision of oral healthcare and the role of the dental team. The Adult Dental Health Survey (ADHS) shows a steady decline in the number of edentate patients in the UK, currently at 6%, a 24% reduction since 19783. Not only are patients living much longer, but will expect to retain their teeth for longer too2,3. In the not too distant past, tooth loss was considered inevitable in advancing years. Nowadays, people (81%) expect to keep their teeth for the duration of their lifetime3 and the UK will need a dental workforce equipped with skills for effective prevention and behaviour change techniques6,7 to ensure optimum oral health for older generations.
A thorough understanding of the relationship between systemic and oral health is essential to prepare for the challenges of an ageing population8,9. Minimal intervention dentistry and advanced restorative materials and methods are some of the ways in which dentistry is evolving to meet the demands of an ageing population who need to retain a functioning dentition well into old age9,10.
It is well established that good oral health is a fundamental determinant of healthier ageing, improved general health and wellbeing10 which reduces physical decline. However, it is more difficult to maintain oral health into older age8-11 due to physical, cognitive and biological changes that occur resulting in reduced independence, mobility and manual dexterity, fragility, healthy illiteracy, impaired cognitive function, financial reasons and access to services11.
The dental team urgently need to adapt to meet the needs of an older patient demographic and reduce the barriers associated with specific needs and challenges. More emphasis on retaining teeth well into old age will demand a more preventive driven health model. Despite the evidence to support that, caries and periodontal disease are for the most part preventable, they continue to create a huge global burden on healthcare and resources worldwide10, and this burden is predicted to grow, as the older population do. The Evidence based research suggests that older adults are more susceptible to dental caries and periodontal disease, due to either longer exposure to risk factors or reduced physical capabilities2,10,11. With an ageing population, comes more emphasis on screening programs for detection of chronic diseases and oral cancers.
Oral Cancer Screening
Screening every patient to facilitate the earlier detection of oral cancer, especially in high risk patients should be performed routinely for every patient. Discussions about the risk factors, smoking and alcohol, that increase the risk of developing oral cancer should be carried out. Appropriate management of detected mucosal lesions and prompt referral are key to improved survival rates. There are 5000 new cases diagnosed each year, with men more at risk than women, and older people more at risk than young. The 5-year survival rate is low12 compared to other cancers with only 48-55% surviving 5 years. The dental surgery provides an opportunity to screen and educate patients about oral cancer and offer smoking and alcohol cessation counselling.
Root Surface Caries
Dental caries is still the most common disease globally and is preventable by adjusting modifiable lifestyle factors1,10. As part of the governments nutritional guidelines, we are all advised that for good health we consume 5 portions of fruit and vegetables each day, however, with scientists recently showing that eating 10 portions of fruit and vegetables a day could prevent a significant number of premature deaths worldwide, there are those whom are now consuming a lot more fruit and vegetables in order to reap the health benefits this could bring. However, with this, and more in those whom are consuming a significantly greater amount of fruit (either dried, fresh, in juice form or as smoothies) this can lead to increased acid erosion, demineralisation and increased caries risk.
The dental team should try to explore the source of dietary acids and sugars, frequency of intake, available fluoride, salivary flow and effectiveness of self-performed oral hygiene practices in a proactive approach to reduce dental caries in older adults. The ADHS found 43% of adults over 65 had restored root surfaces3. A diet analysis diary can help to identify hidden sugars and frequency of snacking. Getting the patient to complete a 3-day food diary can help to identify the amount and frequency of free sugars and acidic foods and drinks in their diet. Suggestions for anti-cariogenic substitutes for snacks (plain popcorn, nuts and cheese) and beverages (water, regular or ice tea, unsweetened almond/ coconut milk) and advise limiting sugary food and acidic foods and drinks to main meals will help to reduce periods of demineralisation.
On identification of high caries risk patients, prescribe a high-level fluoride toothpaste containing 2800ppm or 5000ppm. Topical fluoride varnish is also recommended in Delivering Better Oral Health13 for high risk adults as an effective preventive intervention. A study by Schaeken et al found a 50% reduction in root caries following the application of fluoride varnish every 3 months14.
A reduced salivary flow can alter the buffering capacity and cleansing of the oral cavity resulting in caries. Polypharmacy is common among the elderly (variety of drugs prescribed for multiple conditions) can result in xerostomia, accelerating the progression of caries. On average patients may take 8 to 13 medications per day15. Over 400 drugs are known to reduce salivary flow and this can lead to rapid deterioration of enamel and dentine. A thorough investigation of a patient medical history may highlight interactions or combinations that need re-evaluation by a physician, substitutions that may alleviate symptoms of xerostomia.
Online risk assessment tools, such as Previser (Deppa) has become more mainstream and is designed to determine an individualised patient risk of oral disease by generating a score based on biofeedback (systemic health, lifestyle factors and clinical data). This software produces written guidelines to assist clinicians to communicate information and advice to patient in a more structured manner.
Periodontal & Peri-implant health
Patients are living longer, therefore will need to maintain the health and function of natural teeth and/or their restorative and implant replacements for the duration of their life16. Therefore, improved preventive interventions are necessary to reduce the incidence and progression of oral disease. Once inflammation has resolved, then recall intervals can be further apart. Absence of bleeding on probing (BOP) is considered the most reliable indicator of gingival health17. The ADHS reported attachment loss in 85% in over 65 age group3.There is an increase in the number of patients presenting in general practice with dental implants, implant retained dentures, implant supported bridges and prosthesis.
Formal education of implant care is limited in undergraduate curricula and graduates often report a lack of confidence in this area. Clinicians who are not equipped with the skills required to address the needs of patients with dental implants, should consider additional education and training in this topic. Patients will need more specialised oral hygiene aids and demonstration to facilitate biofilm removal and prevent the onset of peri-implant mucositis and peri-implantitis. Prosthesis must be designed in a manner that facilitates patient self-care18. Patients should know the exact location and number of abutments in their mouth and receive demonstration of effective biofilm control using the most suitable oral hygiene aid for their needs. A wide variety of implant specific tools are available such as single tufted, angular and sulcular brushes and specialised floss.
With old age, patients may develop arthritic hands and fragility, making daily personal hygiene complex and tiring. Power brushes have a wider handle to facilitate grip and control, also eliminates the need to produce tiresome and awkward brush strokes manually. Alterations to floss holders and interdental brushes may improve manual dexterity. Again, clinicians must not assume that patients know effective brushing techniques. Clear, specific and tailored oral hygiene demonstrations will improve periodontal outcomes. Suggest videos and produce written material to support patients to adopt a new skill.
When manual dexterity is compromised, recommend a daily oral rinse, such as a daily fluoride concentration or a broad spectrum antimicrobial, as an adjunct to their mechanical self-care routine. Relatives and carers should be trained to assist or perform oral self-care and remind patients who have difficulty remembering.
Dentine Hypersensitivity
In a study by Baker et al, 70% of respondents reported that dentine hypersensitivity took the pleasure out of eating and 26% were embarrassed to eat in public19. The discomfort and pain experienced has been due to dentine hypersensitivity, as a result of exposed root surfaces, recession, abrasion and acid erosion. Recommend a desensitising toothpaste containing stannous fluoride for daily use to help alleviate symptoms and provide lasting relief. Daily application is required to sustain absence of symptoms. Targeted application of the product to the area is also a useful way to soothe sudden onset of discomfort.
Partial & Complete Denture Care
Patients with partial dentures are at increased risk of further caries and periodontal destruction, due to the nature of the prosthesis. Partial dentures should be removed at night, brushed to remove biofilm and soaked in an antibacterial solution overnight. Brush remaining natural teeth, and gums, paying particular attention to the fitting surfaces of the prosthesis. A single tufted brush provides extra cleaning ability in hard to reach areas that support partial dentures. Edentulous patients have a lower perceived need for dental care20 and reports indicate that 48% of 65-74 year olds and 63% of over 75 year olds have not accessed care in a decade20.
Access to dental services
Barriers to care for an ageing population include access to the dental surgery for persons with reduced mobility and disabilities. The availability of appointments that allow independent living senior citizens to avail of subsidised transportation (freedom pass) to attend dental services without the added cost of travel11, 20. Dental services will also need to reach those who are dependent and living in private housing, those living in residential care and patients in assisted living facilities and the meet the demand for a mobile service provision. The dental professional must also consider the issue of health illiteracy in the over 65 age group and ensure transparent and clear communication regarding treatment procedures, prevention measures and cost, allowing the patient sufficient time to process information, ask questions about their care and make informed decisions about their oral health.
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