Increasing numbers of people are becoming older adults. The “graying” of America has often been described in the media and is well documented by U.S. census. Baby boomers approaching retirement age are expected to make this trend even more pronounced. The age considered to be geriatric usually (and arbitrarily) begins at 65 years. This is entirely an artificial construct; many so-called geriatric processes are well evident in people years younger, and many do not manifest themselves in others until much later. That caveat aside, the transition from “elderly” to “frail elderly,” or between “young old” and “old old,” is characterized by physiological and functional change. This entry discusses these changes, their effects on oral health, and the relationship between oral health and systemic health.
The most common of the oral diseases are the plaque diseases, namely caries and periodontal disease. Plaque is an adherent, gelatinous-like material consisting of salivary components, food residues, and bacteria. Caries is the dental term for tooth decay, and periodontal disease affects the tissues surrounding the teeth. These bacterial diseases are both chronic and progressive in nature. Progressive demineralization of the teeth by bacterial acid causes enamel breakdown (cavities), which can develop into abscess and tooth loss.
Periodontal disease causes destruction of the fibers attaching teeth to bone. Advanced periodontal disease results first in tooth mobility and then in tooth loss. During this process, recession of gum tissues exposes the root surfaces of teeth. Because these root surfaces are not protected by enamel, they are more susceptible to caries. The resulting decay is difficult to treat, and recurrence is common. More than 95% of people age 65 years and older have periodontal damage.
Like all conditions discussed in this entry, the following pathologies are not exclusive to an aging population, but older adults have particular susceptibility.
Fungal infections, such as candidiasis and angular cheilitis, are common among older people. They are usually associated with other medical conditions. People with diabetes who also wear dentures are at particular increased risk, as are those who have suppressed immune systems. Oral candidiasis is especially serious for people who are HIV positive and for those taking immunosuppressive medications. It can spread to the esophagus or lungs, creating an immediate threat to life.
Angular cheilitis is a fungal condition of the lips, causing dry and cracked tissues at the corners of the mouth. If untreated, the lesions can persist indefinitely, with periodic bleeding and occasional secondary infection. It afflicts immunocompromised people, and those who wear dentures have reduced salivary flow. This seemingly minor lesion causes significant misery and decreased quality of life.
Neoplasms range from epulis fissuratim, a benign growth of tissue caused by an ill-fitting denture, to life-threatening malignancies. An epulis can cause irritation, inflammation, and secondary infections. The malignancy most threatening to life is squamous cell carcinoma. It is frequently found on the side of the tongue in the back of the mouth, although it is also found on the lip, palate, cheek, and floor of the mouth. It has a poor prognosis, and successful treatment requires early diagnosis. The survival rate for people with lip cancer is high because these lesions are quite visible, and early diagnosis is typical. Lesions on the floor of the mouth or the side of the tongue have a significantly higher mortality rate. These more posterior lesions tend to be more aggressive, and diagnosis is often delayed because they are hidden from view.
Fully 70% of elderly people suffer from xerostomia (reduced salivary flow). The primary cause is prescribed medications, including blood pressure medications, antidepressants, antihistamines, diuretics, narcotics, and antianxiety medications. Other causes include radiation therapy and substance use/abuse.
Xerostomia is a major contributor to tooth decay and periodontal disease. It impairs chewing, swallowing, and speech. It causes tissues of the lips, tongue, and oral mucosa to become dry and cracked. Loss of intraoral lubrication causes recurrent abrasions and ulcerations. Fungal infections, aphthous ulcers (canker sores), and herpetic lesions all occur more readily in the dry mouth. Xerostomia plus acid reflux produces burning sensations in soft tissue and acid erosion of tooth structure.
Xerostomic people should sip water continuously. Artificial saliva and salivary stimulants such as sugar-free gum help. Gum with xylitol, a noncaloric sweetener, also helps to protect against tooth decay. Topical medications provide some relief. Aggressive disease prevention efforts are an absolute necessity for xerostomic patients.
Fixed prostheses are used to replace missing teeth. They include bridges, which anchor artificial teeth to the remaining natural teeth, and implants, which surgically anchor replacement teeth in bone. Their function is similar to that of natural teeth, and people adapt to them readily. Fixed prostheses require meticulous care, however, and their success depends on the good health of the surrounding tissues.
Partial and full dentures are removable prostheses. Full dentures replace all of the teeth in the arch. They restore some, but not all, function. Denture stability requires a snug fit and maximum contact with broad areas of tissue. People wearing dentures experience loss of taste, reduced proprioception, and impaired chewing ability. A common, but incorrect, perception is that when all of one’s teeth are gone, there is no longer a need to visit the dentist. However, tissues under dentures change rapidly, and resulting pathologies require care. Dentures are implicated in many conditions, including denture stomatitis, traumatic ulceration, fungal infection, and the previously mentioned epulis fissuratim. When dentures no longer fit well because of changes to the underlying tissues, their function is impaired and the risk of oral lesions rises.
Many of the processes of aging affect oral health, including changes in anatomy, cell physiology, gastrointestinal activity, immune function, and sensory integration. Loss of teeth causes reduced appetite, chewing capacity, and taste. Eating habits change, and nutritional capacity is reduced. Tooth loss also contributes to social isolation and depression. Gastrointestinal changes impair digestion and absorption processes, and maintaining adequate nutrition levels becomes more difficult.
Physiological changes affect the metabolism of therapeutic drugs. Altered protein levels in plasma change the transport efficiency and half-life of some drugs. This profoundly affects function and optimal dose, and it increases the risk of overdose. Periodic reassessment of the effectiveness and safety of medications is an essential part of health care for aging adults.
Aging is associated with dysregulation of the immune response even in healthy elderly people. These changes in the immune system may predispose older persons to infectious, neoplastic, autoimmune, and inflammatory diseases, all of which find fertile ground in the oral environment.
Incidence of chronic disease among older people has increased dramatically. Oral health and systemic health are indistinguishable; each affects the other with remarkable consistency. Chronic disease has significant impact on oral health, and oral disease certainly affects systemic health adversely. Existing cardiovascular disease correlates highly with periodontal disease, and oral infections can cause cardiac infections. The valves of the heart are especially susceptible to oral bacteria transported through the vascular system. The resulting infection, called endocarditis, is life threatening and can require surgical replacement of the heart valves.
Diabetes is a prime example of the interrelationship of systemic and oral health. The effects of diabetes on oral health include an increase in oral bacterial infections, periodontal disease, and fungal infections. Conversely, poor oral health creates problems with glycemic control, increasing the difficulty of managing the diabetic condition.
Today, more individuals have multiple chronic diseases, and medication use has risen accordingly. The typical nursing home resident’s pharmacological regimen is eight medications daily. Many of these drugs have profound effects on oral health. Reduction in salivary flow was discussed previously. Calcium channel blockers and antiseizure medications cause gingival overgrowth and increased plaque levels, resulting in bleeding gums, tooth decay, and periodontal disease.
A variety of neurological, musculoskeletal, and inflammatory conditions reduce motor function. Of these, arthritis is certainly one of the most widespread. Reduced mobility from arthritis can deprive people of full independence, reducing their quality of life. Of critical importance is the arthritic’s reduced capacity for self-care. Arthritic hands might not be able to use dental floss or manipulate a toothbrush effectively. The risk of oral disease increases profoundly.
More than 1.75 million people currently live in convalescent care centers. Three quarters of these people have poor oral hygiene. Most need help with activities of daily living (ADLs), and 70% have some level of cognitive impairment. Assisted-living facilities are enrolling increasing numbers of people, many of whom have reduced functional and cognitive capacity. The unmet oral health need of this population is staggering, and the problem is expected to get worse. Untreated oral disease increases demands on the immune system and can lead to systemic infection, with very serious consequences for frail seniors.
Oral health is particularly poor among people with dementia. Oral hygiene is difficult, and the need for dental care is extremely high. Most of these needs are never addressed satisfactorily, and dental disease is largely untreated. Communication difficulties often cause oral pain not to be reported. Diagnosis of oral problems from behavioral anomalies is difficult, and most often the real oral difficulty remains unaddressed. Even when care is accessed, it is often limited to emergency care rather than the ongoing comprehensive care needed to maintain good oral health.
Oral problems such as pain and reduced salivary flow affect nutrition, weight, hydration, speech, behavior, and social interactions. Loss of function is evidenced by impaired speech, impaired digestion, and reduced chewing capacity. Effects of acid reflux can be devastating. Loss of muscle tonicity makes dentures less functional and more uncomfortable. Sleep apnea is common. In short, reduced functional capacity and cognition can diminish oral health profoundly, exacerbate systemic health problems, and reduce quality of life substantially.
The oral condition can enhance or impair the capacity for nutrition. Oral factors that reduce nutritional capacity include tooth loss, pain, denture use, oral pathosis, and xerostomia. Infection and inflammation reduce appetite. Tooth loss restricts types of food that can be eaten. Meat, fresh fruits, and fresh vegetables are difficult to eat if diseased teeth are loose or painful.
In an aging population, chewing, swallowing, and digestion are often impaired. Dietary restrictions are common, collagen metabolism can be dysfunctional, underlying medical conditions abound, osteoporosis is common, and substance dependency is rising and is largely untreated. The supplements used to maintain nutrient supply lack necessary dietary texture and fiber for normal gastrointestinal function. For all of these reasons, adequate nutrition and good eating habits are critical for geriatric health.
Micronutrient depletion is directly associated with oral pathology. Mucosal lesions are linked with iron deficiency, and reduced calcium absorption contributes to osteoporosis. Reduced vitamin absorption impairs mucosal cell metabolism, collagen metabolism, and the healing response. Vitamin D facilitates intestinal absorption of calcium, and it is instrumental in bone remodeling. Aging people experience a fourfold decrease in the ability of the skin to produce Vitamin D. Even healthy older people have been found to have low dietary intakes of iron, folate, calcium, magnesium, and zinc.
Vitamin C is the nutrient most associated with oral health. It has antioxidant properties preventing cell damage. It acts as a cofactor in collagen synthesis, essential for connective tissues, blood vessels, and bone. Vitamin C is involved in DNA/RNA synthesis, essential for new cell growth. Given that mucosal cells replace themselves every 3 to 7 days, this is of particular importance. People at risk for an insufficiency of Vitamin C include those who eat few fruits and vegetables, those with restricted diets, those with chronic illnesses, and those who are substance dependent. This description fits far too many aging people far too well.
The nutritional effects of losing teeth are often underestimated. Even excellent dentures do not work as well as natural teeth. Over time, denture wearers experience alveolar bone loss, making the dentures unstable or unwearable. Chewing becomes painful, and people eat mostly soft foods. Seniors are second only to persons 15 to 24 years of age in the amount of processed foods and refined sugars they eat. Such a diet increases risk of obesity and dental disease.
Psychosocial changes in an aging population lead to lifestyle changes. Many people can make adjustments to accommodate mental, emotional, and physical changes. Adaptive change that maintains independence also maintains quality of life. Loss of independence reduces the ability to engage in everyday activities such as shopping and preparing meals. Lack of exercise, reduced social interaction, and inadequate nutrition adversely affect wellness. Depression and isolation further reduce functional capacity and quality of life.
New onset substance dependency is developing at alarming rates among aging adults. The substance of choice is usually alcohol or prescribed medication. Substance dependency has a profound effect on both oral and systemic health. Alcohol use, particularly in conjunction with tobacco use, increases the risk of oral cancer. Other oral effects include xerostomia, attrition of the teeth, dental hypersensitivity, and poor oral hygiene. Alcoholics may suffer from gastrointestinal bleeding and impaired absorption. People with active substance dependencies do not take good care of themselves, and oral health deteriorates rapidly.
Reduced mobility and physical incapacity limit access to oral care, even for those with sufficient financial assets. One third (33%) of men and nearly half (45%) of women are expected to spend parts of their lives in nursing homes. Unfortunately, regular and consistent oral health care is in very short supply in assisted-living situations. Residents must depend on others for even the most rudimentary oral hygiene. Reduced personal oral hygiene inevitably leads to poor oral health. Access to services of dental professionals is limited by transportation difficulties and the scarcity of professionals willing to make house calls. The result is reduced access for people just as their need for care is escalating.
Many people approaching their “golden years” have an image of senior life as people in good health enjoying a plethora of recreational activities as a reward for well-lived lives. For many, this picture will be accurate. Many others, however, will experience the personal dissonance of the cultural promise not matching the reality. The sheer number of people entering their senior years will substantially increase oral health needs. Medicare does not cover oral health costs, and many older people with fixed incomes are unable to pay for care themselves. The challenge for policymakers and health care providers will be to develop effective ways of addressing these needs.
Anticipating the physiological changes associated with aging can enhance quality of life. Knowing what to expect and how to prepare for the changes of aging will do much to help people enjoy life during their later years. Regular care and personal measures of prevention will promote oral and systemic health and, therefore, a better life. Health care oriented toward wellness will enhance the quality of that life. Health begets health, and at no time is this more evident than during the senior years.
Health Promotion and Disease Prevention; Nutrition, Malnutrition, and Feeding Issues; Smoking
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