Oral health concerns for the Aging Population

Introduction:

It is a well-known fact the American population like several other populations of

the west has begun to age. Currently, 13.7% of the US population is over 65 years and is

expected to be about 25% in the next 10 years. By the year 2011, the geriatric population

is expected to grow at a rate of 126%, in comparison to the over-all population growth

rate of just 42%. The average US life expectancy has risen from 47 years in the year 1900

to 74 years for the year 2000. This tremendous growth rate obviously necissates an

important attention to be paid by health policy makers. As the population begins to age,

the number of adults with acute and chronic conditions increases. Oral health is one such

aspect, which has often, not being given its due. It is necessary to realize and underscore

the significance of good oral health by the geriatric population. In other words, it

becomes necessary to understand the various ways by which oral health can be

detrimental to the general health.

Oral health problems are often a cause of pain, suffering and spread of infection.

The geriatric population is more susceptible to systemic conditions, making them

predisposed to developing various oral diseases. Tooth loss is associated with poor

nutrition which affects the quality of life of an individual. In addition, it also leads to poor

self esteem, speech defects, improper swallowing and mastication. Oral diseases may also

complicate the intake of medicines for various systemic diseases, which are concurrently
prevalent among the geriatric patients. Current research is focusing on relating oral health

to the prevention of heart disease, stroke and diabetes mellitus. Thus, oral health

concerns, which are not necessarily a direct cause of death, play an important role in the

over-all well being of an individual.

Gerodontology refers to that branch of dentistry, which deals with various

diseases and problems of the elderly population. Geriatric dentistry is the practice of

dentistry on elderly people, and deals with special knowledge, attitudes and technical

skills required in the provision of oral health care to older adults. It is important to know

that these are just applied terms and the American Dental Association has not yet

recognized geriatric oral care as a specialty in dentistry.

Oral health and Older Americans:

The ‘Conceptual Model of Aging and Health’ is a very good paradigm to

explain this phenomenon. In this the socio-cultural environment shares a reciprocal

relation with the Social-Individual Aging and the Psychosocial mechanisms. The Social-

Individual aging is reciprocal with the components of Health attitudes and behaviors and

Health outcomes, which are interconnected as well. The Psychosocial mechanism has a

reciprocal connection with the Health attitudes and behaviors and Health outcomes.

The average US life expectancy has risen from 47 years in the year 1900 to 74

years for the year 2000, and is expected to rise even more in the future years. This

implies that there are more number of older adults, who are keeping their natural teeth

than ever before. The oral health ailments comprising of cavities, gum diseases, oral
cancer and other infections afflict more Americans than any other group of ailments. The

baby boomer generation will probably be the first where the majority of the population

will maintain their natural teeth over their entire lifetime, having obtained the benefits of

water fluoridation and fluoride toothpastes. However, among those aged 65 years, about

30% of them have untreated dental caries (cavities) and slightly over 40 percent have

periodontal diseases. In spite of the decline in tooth loss in US adults, the need for

various other types of dental services in the adult population continues to increase.

Unfortunately, for most Americans, oral health is viewed as more of a “luxury” than as a

necessity. It has also been observed among this population that, those in poverty are twice

as likely as those with higher incomes to be edentulous (lose their teeth). Another

important consideration of this aging population, with regards to oral health is that they

consume 30% of all prescription medications, many of which can have a negative impact

on oral health.

Many older Americans take medications such as antihypertensives,

antihistamines, diuretics, hypoglycemics and antidepressants for various chronic

conditions that have side effects detrimental to their oral health. Furthermore, only 22

percent of older persons in the United States are covered by dental insurance, making

most of the elderly dental expenses to be paid out-of-pocket. Even the insurance policies

have a coverage level of “D”. It is rather unfortunate that not even a single older

American receives dental care under Medicare and Medicaid provides only limited

coverage in certain states; the majority of the older adults lose their dental insurance

when they retire. Most uninsured older Americans with a severe oral disease, eventually

seek hospital care, where a radical method of treatment becomes inevitable, costing
millions of dollars to the economy. Another factor adding to the complication is the

concurrent debility or systemic disease that cripples the average American older adult

which leads to continued accumulation of oral diseases. Epidemiological research on

periodontal disease (gum disease) in older adults confirms the same and suggests that the

disease in older adults is probably not due to greater susceptibility but, instead, the result

of cumulative disease progression over time. It has been observed that over 5% of people

aged 65 and above live in long term care facilities, where oral health care is neglected. In

addition to poverty, the other contributory factor to this US population is its diversity in

ethnicity, religion and culture all of which seem to influence the consumption of oral

health care.

Limited access to oral health care poses as one of the main hurdles in the

delivery of care to Americans. The most common way of seeking oral health care by a

US older adult is through a dental visit. Data available on the use of dental services has

shown that dental visits by older adults correlate with the presence of teeth and not the

age. The challenge to obtain care is even more complicated by the lack of skilled

personnel, who are specialized to deliver care for the geriatric population.

Common clinical conditions and their sequel in the older adults:

Dental Caries:

Dental caries (cavities) is one of the most common infectious diseases known to

man, and older adults are not an exception. Though nature provides a protective

component in older teeth in thwarting the progression of caries, yet it is an important

condition and draws attention. Data indicates that between the years 1988 to 1994, 1/3rd
of the population above 65 years had untreated dental caries on their tooth. Of particular

interest with respect to the longer retention of teeth among older adults, is the condition

called root caries. This basically refers to dental caries occurring on the exposed root

surfaces, due to the recession of the gum line, a normal occurrence in elderly people. The

sequela of dental caries is the invasion of the dental pulp followed by the infection and

inflammation of the supporting tissues of the tooth, which will cause severe pain, fever

and affects the mastication of food. This is certainly a detrimental component of the oral

health of the older adult.

Periodontitis:

Periodontal disease refers to the infection and inflammation of the supporting

tissues of the tooth. This may occur as a result of poor oral hygiene, which leads to the

inflammation of the gums, which eventually progresses further to destroy the supporting

tissues. The tooth becomes mobile as a result of this sequela and the patient eventually

loses his or her teeth. Periodontitis deserves attention due to its common-ness of

occurrence and for its ability to jeopardize the masticatory apparatus of the individual.

Maintaining good oral hygiene and routine dental care can prevent periodontal disease.

Xerostomia:

The term xerostomia means dry mouth. It is a very common condition seen

among the elderly people. Its causes vary from a physiological atrophy of the salivary

glands to certain infections. However, one of the most common causes is due to

medication. The geriatric populations have a number of concurrent systemic diseases to

combat with, and depend upon a number of medications. The side effects of these

medications lead to xerostomia. Xerostomia can affect an individual by an irritable

sensation, discomfort, lack of taste in food, constant feeling of thirst and improper

retention of dentures.

Oral Cancer:

It is well known that oral cancer has a very high chance of occurrence in an

elderly man who is a smoker. It commonly occurs on the tongue, lips and the floor of the

mouth. Oral cancer is a growing concern in the United States, and its early detection

certainly increases the chances of survival of the patient. Past statistics indicate that in the

year 1997, there were about 5000 deaths due to oral cancer. With routine dental check-

ups, the probability of an early detection is increased.

Other conditions:

Several other conditions complicate the oral health of the older adult. Candidiasis

is the most common opportunistic infection in the world and occurs most commonly in

the oral cavity. The disease occurs when immunity of an individual is compromised, as is

the case of older individuals. Certain other conditions like Temporo-mandibular

dysfunctions, myalgias, and various other conditions are topics that deserve attention

with respect to the older adult.

Complex issues and barriers related to obtaining oral health care:

There are several complex issues affecting the delivery of oral health care to the

geriatric population. The first and foremost concern is the perception of oral health by the

geriatric population. Most of today’s American population aged over 65 years has

significant financial issues to be dealt with, which adds to the negligence of oral health

care. Oral health has often been viewed as “luxurious” and thus is a victim of
compromise and negligence. Adding to this are the ever-ascending costs of dental care,

lack of insurance and lack of coverage from Medicare. Complicating this issue is the

inadequate access to oral health care when needed. Furthermore, inadequate patient

compliance such as failure to keep up with dental appointments, failure to follow

dentist’s instructions and failure to take medications complicates the issue.

Viewed three dimensionally, the other complicating issues include concurrent

systemic conditions and intake of prescription medications which affect the physiology of

the oral cavity. In addition, older adults have decreased motor skills and coordination,

which makes the performance of oral hygiene, difficult at home. Finally, it is the lack of

knowledge and motivation from self and from family members is a significant issue.

Fortunately, almost all of these complex issues listed above can be taken care of, with a

co-coordinated effort by the health policy makers and the practitioners.

Attitude of Dental professionals:

There appears to be a decreased sense of interest and motivation among the

dental professionals towards geriatric care. Some of the possible reasons are lack of

financial incentives, poor patient compliance, lack of experience, special skills as well as

fear when treating geriatric problems. In addition, legal and social issues, a mediocre or a

negative attitude toward the older adult’s need for dental care as well as some specific

problems that need to combated in providing dentistry to homebound and

institutionalized patients, result in a laid-back attitude towards dental professionals. The

above problem can be solved, by dealing with a number of issues. Firstly, education and

specialization so as to deliver care specifically to the older adults need to be incorporated.

 The conventional educational and practice structures currently being followed are

often accused of being based on only serving the needs of a healthy and affluent

population. Specific attention to geriatric care will provide more ‘specialists’ with

improved quality of care. This will result in improved financial incentives and arenas for

improved marketing of care.

Future of oral health care for American older adults:

It has to be certainly acknowledged, that in recent years, there has been a positive

shift of balance towards oral health care. With more number of people retaining their

teeth for a longer period of time, there is an emergence of special kinds of problems,

which require specialized care. Currently, the burden of providing much of the dental

care for the aging population rests with the private dental practitioner. This makes him

vulnerable to get fatigued too soon, much at the compromise of providing quality care to

the older adults. The future of oral health care in America calls for more elaborative

policies by the government, which should include the provision of insurance policies,

coverage under Medicare and incentives to the dental professionals seeking to practice

geriatric care. Of special concern, is the provision of oral health services to a functionally

dependent elderly population unable to access oral health care services in the traditional

manner. This could be done thorough several ‘mobile care units’ which brings dental

care at the doorstep. Ideally, the older adults should receive care from specialist in

geriatric care due to the nature of the care demanded. This necessitates the Universities to
go beyond routine references and enable this branch of dentistry to grow and promote

the recognition it deserves by fully integrating geriatric dentistry into their programs.

In conclusion, the demands for oral health care in the Unites States will continue

to grow, and this demands the tackling of three chief concerns – access to care,

specialized personnel and financial concerns. There has been a tremendous amount of

recognition and outpour of literature in this issue in the recent past, and now it is up to

the policy makers to ensure that the concerns are addressed.

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