36

retain more teeth as they age. The most likely explanation for
this is the availability of affordable, relatively pain-free oral
health care. This has resulted in people being less willing to
have teeth extracted, particularly in the esthetic zone at the
front of the mouth (Fig. 2) (Fuller et al., 2011). In less developed
parts of the world, teeth are also retained into old age because
dentists are not available to extract them in the first instance.
There are few data reporting the oral health state of older popu-
lations from the developing countries; those that are available
record evidence of active disease.
Thus, the profession is faced with an increasing number of
older people with teeth, leading to different patterns of dental
disease and greater opportunity for interactions with systemic
disease.
INTERACTIONS WITH SYSTEMIC DISEASE
The evidence for a relationship between inflammatory oral dis-
eases and both cardiovascular disease and type 2 diabetes has
been well-established (Cullinan et al., 2009). However, there is
a host of medical and degenerative conditions which occur with
increasing prevalence in older populations that may affect the
severity of dental caries through two fundamental mechanisms:
the side-effects of polypharmacy that result in reduced sali-
vary flow (Nrhi et al., 1999); and
a reduced ability of the individual to maintain his/her per-
sonal oral hygiene, resulting in plaque accumulation through
either frailty or incapacity as a result of arthritis or sarcope-
nia (muscle wasting) (Doherty, 2003).
Polypharmacy is commonplace in modern Western countries
as patients get older and present to their medical practitioner with
the common diseases associated with aging. Numerous drugs
interact with the secretory pathways for salivary output, where
both and adrenergic, muscarinic, cholinergic, and peptidergic
stimuli are involved in its central regulation, calcium channel
signaling is critical to the regulation of acinar cellular function,
and water balance affects overall secretory rates. Drug regimes
for common medical conditions can block such pathways, with a
cumulative effect on salivary flow (Nrhi et al., 1999).
Frailty, sarcopenia, and dementia can all have effects in
terms of an individuals ability to undertake personal oral health
ABSTRACT
The population of the world is aging. A greater proportion of
older people are retaining increasing numbers of natural teeth.
Aging is associated with changes in oral architecture and muscle
weakness, making personal oral hygiene more difficult, particu-
larly for the oldest and most frail individuals. Furthermore, there
is exposure of root dentin with its higher pH for demineraliza-
tion in addition to enamel as a substrate for caries. Aging is also
associated, for many in the developed world, with taking mul-
tiple medications, with the associated risk of dry mouth. These
variables combine to increase caries risk in older vulnerable
populations. Caries occurs on both the crowns of teeth (pre-
dominantly around existing restorations) and the exposed roots.
Prevention needs to be aggressive to control disease in this com-
bination of circumstances, with multiple strategies for limiting
the damage associated with caries in this population. This paper
explores the evidence that is available supporting preventive
strategies, including fluorides in various forms, chlorhexidine,
and calcium phosphate supplementation.
INTRODUCTION
T
he population of the world is aging, with the greatest propor-
tional increases occurring among the most elderly (Fig. 1)
(ONS, 2011). These changes have occurred as a result of pub-
lic health measures reducing or eliminating the causes of infant
and child death. Thus, more children are growing into adulthood.
Additionally, life expectancy has also increased for adults, as a
consequence of improvements in their diet and lifestyle and with a
relatively small additional benefit from modern health care. These
changes have been at their most dramatic in the later part of the
20
th
century and the early part of the 21
st
(Table), and are predicted
to continue for the foreseeable future (Oeppen and Vaupel, 2002).
Simultaneously with the increasing numbers of older people
in the developed world, there is a general trend for people to
A.W.G. Walls
1
* and J.H. Meurman
2
1
School of Dental Sciences, Framlington Place, Newcastle upon Tyne,
NE2 4BW, England; and
2
University of Helsinki, Institute of Dentistry,
BOX 41 (Mannerheimintie 172), Helsinki 00014, Finland; *correspond-
ing author, angus.walls@newcastle.ac.uk
Adv Dent Res 24(2):36-40, 2012
Key Words
oral hygiene, caries detection/diagnosis/prevention, fluoride(s),
geriatric dentistry, gerontology, root caries/resorption.
DOI: 10.1177/0022034512453590
International & American Associations for Dental Research
Approaches to Caries Prevention and
Therapy in the Elderly
Adv Dent Res 24(2) 2012 Caries Prevention and Therapy in the Elderly 37
care. Additionally, the increased complexity of the oral architec-
ture through gingival recession makes cleaning more complex,
while changes to vision make it difficult for older people to see
what they are trying to achieve. The outcome is an increase in
plaque on surfaces that are difficult to clean and that often com-
prise dentin rather than enamel with its inherent higher pH for
demineralization a recipe for caries. There are no significant
data in the literature addressing the effectiveness of oral hygiene
in older rather than younger populations.
CARIES
There is an inevitable focus on root caries in older people; how-
ever, analysis of these data suggests that coronal lesions are more
common than root lesions (Fig. 3) (Graves et al., 1992; Drake
et al., 1997; Hamasha et al., 2005). These coronal lesions occur
mainly as caries associated with restorations (CARS). There is a
dearth of information in the literature about CARS and its etio-
logical variables. Analysis of the available data suggests that it
most commonly occurs on the surface of a tooth adjacent to a
restoration, at its gingival extent, and in association with over-
hanging margins to restorations or substantial marginal defects
(Mjr, 2005). Diagnosis of CARS is difficult even for experi-
enced dentists, and there are few data available to suggest how
it should be prevented other than general caries-preventive
strategies.
It might be expected that the incorporation of fluoride into a
restorative material should limit decay around the margins of the
restoration; however, there is little evidence to support this.
There is largely anecdotal evidence that silicate cements had
relatively low rates of CARS. Glass-ionomer cements (GIC)
also release fluoride in a sustained manner and are capable of
Figure 1. Projected population growth for the UK, 2010-2035. There is an overall increase in population numbers along with a marked increase
in people over the age of 60 yrs (ONS, 2011).
Table. Changes in Life Expectancy at Birth from 1940 to 2020 in the USA
1940 1960 1980 2000 2020
All groups 62.9 69.7 73.7 76.8 79.5
Male (white) 62.1 67.4 70.7 74.7 77.7
Female (white) 66.6 74.1 78.1 79.9 82.4
Male (black) 51.5 61.1 63.8 68.2 72.6
Female (black) 54.9 66.3 72.5 75.1 79.2
For all groups, life expectancy has increased progressively, with a reduction in the differential between black and white populations (data from
United States Environmental Protection Agency, 2012).
38 Walls & Meurman Adv Dent Res 24(2) 2012
acting like a fluoride reservoir when exposed to high fluoride
concentrations in the local environment. However, a narrative
review of their use as restorative materials showed no demon-
strable benefit in terms of caries inhibition (Randall and Wilson,
1999). This finding could be explained by the low rates of fluo-
ride release from current formulations of these materials. One
other possibility is that the studies that Randall and Wilson
reviewed were not powered to detect caries: They were largely
studies designed to assess retention, marginal fit, and color
match of restorations, of limited duration in individuals with
low caries rates. There is one RCT comparing GICs with com-
posite resins in a high-caries-risk population with radiation-
induced xerostomia (McComb et al., 2002). This showed that
caries developed around restorations in all arms of the trial, but
the rate of caries development was lower in teeth restored with
either GICs or light-activated GICs. This suggests that there
may be a limited protective effect that can be readily detected
only when care in a high-risk population is assessed.
CARIES RISK
All of the variables associated with caries risk in younger people
remain valid in an older population, so sugar intake and poor
oral hygiene remain key (Steele et al., 2001). Sugar intake and
the frequency thereof in most individuals can be regulated as
part of diet. However, there are two circumstances where this is
not the case.
Increasingly, medications with prolonged oral clearance
(POC) are being used in older populations. While great efforts
have been made to eliminate sugars from POC medications for
children, similar efforts have not been made at the upper end of
the age spectrum. Many drugs are available in a sugars-free
formulation, but these must be explicitly prescribed. Generic
prescribing and medications bought over-the-counter are both
more likely to result in the elderly ingesting sugars-containing
drugs (Baqir and Maguire, 2000).
One challenge that can be associated with medical care for
older people who are ill is difficulty in getting them to eat suf-
ficient calories as part of their food consumption. In this case,
high-energy liquid food supplements may be prescribed. These
typically contain 1.5 Kcal/mL consumed in a mix of simple and
complex carbohydrates. They are universally sweetened with
sucrose and often consumed on an ad libitum basis from a sip-
ping cup or similar device. This pattern of consumption can
result in a very high frequency of daily sugar intake.
Plaque accumulation can be associated with poor personal
hygiene but is also linked to the use of a removable partial den-
ture (RPD). Caries risk is significantly elevated in those with an
RPD compared with those without (Jepson et al., 2001).
PREVENTION OF CARIES
Fluoride
Fluoride remains the mainstay of prevention in older people. We
know that individuals living in communities with water fluori-
dation develop fewer caries lesions on both the roots of their
teeth and the crowns (Griffin et al., 2007). Furthermore, we
know that adults who began drinking fluoridated water after the
completion of their tooth development also develop fewer root
caries lesions (Brustman, 1986).
Fluoride in toothpastes is effective at reducing root caries
activity, with both conventional 1,000-ppm-F pastes (Jensen and
Kohout, 1988) and also with higher-concentration pastes (typi-
cally 5,000 ppm; Ekstrand et al., 2008). Ekstrand et al. com-
pared 3 prevention regimes based on fluoride in a high-risk
population (home-bound individuals aged 75 yrs and over),
using a 1,450-ppm-F paste, a 5,000-ppm-F paste, or a 22,600-
ppm-F varnish over an 8-month period. Individuals in the 5,000-
ppm group (12.5%) and the fluoride varnish group (17.3%) had
significantly more reversals in caries diagnosis than those using
the 1,450-ppm paste (5.6%) alone. There was no significant dif-
ference between the varnish and 5,000-ppm paste groups
(Ekstrand et al., 2008).
Fluoride is also available in a variety of supplementary deliv-
ery vehicles as rinses, gels, foams, and pastes. Analysis of the
Figure 2. Proportion of the population who were edentulous in England
and Wales, 1968-2009. The trend line shows the cohort effect for indi-
viduals 35 yrs old in 1968 to 75+ in 2009. This suggests that the rate
of edentulism within the cohort fell from 1988 to 2009. This is biologi-
cally impossible and likely reflects increased rates of mortality in the
edentate compared with the dentate (Fuller et al., 2011).
Figure 3. Incidence of coronal and root caries from 2 longitudinal
cohort studies of aging individuals. The incidence of coronal caries
was higher than that of root caries in both populations. The incidence
of root caries was lower in the black sample in the Piedmont com-
pared with the white sample (Graves et al., 1992; Drake et al., 1997;
Hamasha et al., 2005).
Adv Dent Res 24(2) 2012 Caries Prevention and Therapy in the Elderly 39
limited data available suggests moderate effectiveness for low
strength NaF rinses, 1.1% NaF pastes/gels, and 5% NaF. There
are also limited data that support mixtures of different forms of
fluoride, for example, a combination of amine fluoride and
potassium fluoride in both a paste and rinse with 67% reversal
from soft to hard for the combination compared with 7% for
toothpaste alone at 12 mos (Petersson et al., 2007), or Vale et al.,
who showed an additive effect of a single APF application
alongside thrice-daily use of an 1,100-ppm-F paste in an in situ
study (Vale et al., 2011).
While it is well-recognized that different chemical forms of
fluoride have various methods of activity in inducing remineral-
ization in enamel, there are no comparable data for caries that
initiates on dentin, so extending claims for greater efficacy of
one form of fluoride over another would be inappropriate.
Chlorhexidine
A recent systematic review concluded that there was no benefit
from the use of chlorhexidine as a mouthrinse in reducing root
caries activity (Slot et al., 2011). However, there is some evi-
dence of benefit where it is used as part of a caries risk assess-
ment model (Featherstone et al., 2012). The PACS study
examined the use of a 10% chlorhexidine acetate varnish in
terms of caries prevention, with an aggregate result of no ben-
efit in preventing the development of caries. However, 50% of
the study population had very low risk for caries. In the high-
risk urban poor and Navajo Indian arms of the study, where
individuals had substantial amounts of active disease, there was
a significant reduction in caries activity in the test group, indi-
cating benefit for this product in high-risk populations. [These
data are presented in the online Appendix to the main paper
(Papas et al., 2012).]
Ozone
There is limited evidence that the direct application of ozone to
root-caries lesions can result in reversal of caries status (Brazzelli
et al., 2006)
Prevention in High-risk Populations
Decay experience is worse among people with xerostomia and
people living in long-term care.
Individuals with xerostomia develop a wide range of clinical
problems that stem from reduced salivary output, including
rapidly progressing caries lesions and erosive-pattern tooth
wear. These are the consequence of impaired oral clearance of
acids and sugars; reduced buffering capacity, limiting the poten-
tial for neutralization of plaque acids; and lower levels of cal-
cium and phosphate in saliva, limiting the remineralization
potential (Ship et al., 2002). There are three potential strategies
for alleviating these problems.
Stimulation of salivary flow can be achieved with either
mechanical or gustatory stimuli or the use of sialogogues like
pilocarpine or cimeviline (Ship et al., 2002).
Regular chewing of gum has the effect of increasing salivary
output generally as well as stimulation while chewing from the
direct effects of chewing and taste. There are practical limits to
the amount of sugars-free gum that can be consumed because of
the risk of osmotic diarrhea caused by the bulk sweeteners used
as sugar replacements (Mkinen, 1984).
The use of pharmacological stimuli is limited by the side-
effects of cholinergic agonists that include increased heart rate,
night sweats, and frequency of micturition. In practical terms,
intake of these drugs is often limited by the individuals toler-
ance of the side effects. Obviously, there must be some salivary
function remaining for these drugs to be effective (Fox, 2004).
Artificial Replacement of Saliva
A wide spectrum of artificial saliva formulations is available.
These vary in complexity from simple glycerine preparations
through to complex products based on carboxymethylcellulose
or animal mucins, some of which also try to replace elements of
the small host-defense peptides that are involved in a local
immune response. It is important for dentate individuals to
avoid products that have inherently low pH, often because a
citrus flavoring has been added (Fox, 2004).
Adjunctive Preventive Strategies to Reduce
Demineralization
Numerous adjunctive strategies have been assessed in individu-
als with xerostomia. These include combinations of fluoride and
chlorhexidine, high-concentration fluorides including varnishes,
and supersaturated calcium phosphate mouthwash. Generally,
all adjunctive therapies have been shown to induce remineral-
ization and reduce the formation of new lesions when compared
with a standard fluoride-containing toothpaste (Meurman and
Gronroos, 2010).
There have been several attempts to reduce caries activity in
nursing home populations, with mixed results. This population
is at particular risk of caries because of their often impaired
ability to perform personal oral hygiene and the high frequency
of sugars intake that seems to exemplify an institutional diet.
Simons et al. showed clearly that those residents who requested
assistance with their personal oral hygiene had worse plaque and
denture debris scores and higher levels of caries and both yeast
and lactobacilii counts than those who were functionally inde-
pendent in terms of oral hygiene (Simons et al., 2001).
Tan et al. (2010) and Ekstrand et al. (2008) both showed that
various forms of supplementary prevention were effective in
reducing the development of caries in these populations. There
were few differences among the various interventions, which
included:
regular use of a 5,000-ppm-F toothpaste,
monthly application of a 22,600-ppm-fluoride varnish,
3 monthly applications of a 4% chlorhexidine varnish,
3 monthly applications of a 5% NaF varnish, and
annual application of a 38% silver diamine fluoride.
SUMMARY
Globally, the number of older people who are retaining their
teeth is growing. On a population basis, they will have increased
40 Walls & Meurman Adv Dent Res 24(2) 2012
caries risk, particularly those who are dependent on others for
care and people taking multiple medications as a result of poly-
pharmacy. There are few data available that address risk for
caries associated with existing restorations. Fluoride release
from restorations at currently available levels may have some
benefit, particularly in high-risk populations.
Personal oral hygiene can be a challenge in this population
due to altered manual dexterity, sarcopenia, and altered oral
architecture. There are few data available to allow for evidence-
based advice on strategies for personal oral health care.
Fluoride is an effective agent in helping to prevent caries in
the older person, with evidence that an increased concentration
of fluoride and/or use of multiple methods of fluoride delivery
is of increasing benefit.
There is very limited evidence for the use of calcium phos-
phate preparations as an adjunct to a fluoride-containing tooth-
paste in this population, and that which is available comes from
high-risk populations with xerostomia. The evidence that is
available suggests significant clinical benefit.
The use of chlorhexidine as a varnish or rinse, again as an
adjunct to a fluoride-containing toothpaste, also appears to have
some clinical benefit in high-risk populations.
ACKNOWLEDGMENTS
The authors acknowledge grant funding from the UK Medical
Research Council, Biotechnology and Biological Sciences
Research Council, and The Richardson Trust (to A.W.G.W.) and
EVO TYH 3245 Helsinki University Central Hospital, Medical
Society of Finland (to J.H.M.). The authors declare no potential
conflicts of interest with respect to the authorship and/or publi-
cation of this article.
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