Assessment and Management of Oral Conditions in
the Aging Population
Xerostomia
In addition to drugs, several diseases affect the salivary glands resulting
in xerostomia. These diseases include Sjögren’s syndrome, HIV/AIDS,
diabetes, and Parkinson’s disease. Other causes of xerostomia include
injury to the head or neck that damages the nerves that stimulate the
salivary glands, or radiation therapy for a cancer of the head and neck
that damages any or all salivary glands included in the field of radiation.34
Age
does not affect salivary gland production, other than a slight decrease
of the secretion from the serous/mucous glands under conditions of minimal
or extended stimulation.54 Oral
clearance, speaking, oral comfort, denture retention, and caries resistance
are all impaired to some degree by xerostomia, because the saliva that
is present is often more viscous rather than watery. Dry mouth can also
contribute to halitosis, periodontal disease, increased caries, and sinus
problems34 (Figure
5).
A dry mouth also can make swallowing more difficult. Dysphagia, due to xerostomia, can be relieved by eating a soft nutritious diet an drinking plenty of fluids with meals. Patients who have dysphagia due to neurogenic disorders such as cerebrovascular accident, Alzheimer’s disease, and Parkinson’s disease should be managed more carefully due to the increased risk of aspiration. Esophageal strictures, secondary to radiation of the head and neck, can also impede swallowing.54
The aging process is not responsible for decreased taste acuity. Dysguesia may develop from such factors as poor oral hygiene, tobacco use, xerostomia, and medications that interfere indirectly with the mechanism of tasting. Nutritional intake may be compromised due to unpleasant tasting foods. Management would include addressing contributing factors and increasing taste perception by adding flavoring agents or spices to foods.58
Management
of xerostomia, regardless of etiology, is the same. Particular measures
that can be utilized can be found in Table
II. Dental caries, fluoride supplementation, and diet Root
caries is the most prominent form of tooth decay in older adults (Figure
6). Bacteria attack exposed roots more rapidly primarily due
to the greater surface roughness of roots, their greater organic content,
and their ability to breakdown at a higher pH.3
There are other factors that contribute to root caries in the older adult.
Many times individuals will try to remediate the effects of a dry mouth
by using mints, sour candies, or sugared chewing gum, which only increases
their risk of developing root caries. Diets composed of sugary or sticky
fermentable carbohydrates will have the same result. Other predisposing
factors include abrasion or erosion at the cementoenamel junction junction
and root defects derived from clasps on removable partial dentures. These
areas are usually difficult for a patient to clean.34
Persons of advanced age may not report or appear to be in pain from advanced caries or prior restorations. During the aging process, the secondary dentin slowly diminishes the size, vascularity, and sensitivity of the dental pulp.3 The older patient is desensitized to the pain that would ordinarily exist with pulpitis. Usually a fractured tooth or a soft tissue laceration will clue a patient that a problem exists. Often local anesthetics are not needed due to the decreased sensitivity of the teeth.
Management of dental caries should focus on prevention. Proper tooth brushing technique is paramount to eliminate or minimize gingival recession and to reduce the incidence of root caries. Routine application of fluoride varnish on exposed root surfaces during recall visits also is suggested. Fluoride consumption in water and use of fluoride containing toothpaste is a necessity. Concentrated daily fluoride dentifrices should be prescribed for patients at risk. A daily fluoride gel applied in custom trays is recommended for patients at risk for rampant decay due to head and neck radiation, for example.8
Periodontal
disease and oral hygiene
Gingivitis
and chronic periodontitis are the most common periodontal diseases affecting
older adults.5 The
role of periodontal pathogenic bacteria in disease development and progression
is primary, along with contributing factors such as tobacco use, systemic
disease, and physical and/or mental impairments that may impede the patient’s
ability to perform home care. The percentage of adults with 6 mm or more
of gingival attachment loss at one or more sites increases with advancing
age. Nineteen percent of 55 to 64 year olds and 23.4% of 65 to 74 year
olds exhibit attachment loss > 6 mm.44
Daily oral hygiene must be tailored to meet the needs of the independent older adult, the independent older adult with special needs, and the institutionalized older adult with varying degrees of dependency. Due to the challenges of arthritis, impaired coordination, and decreased grip strength, older adults may need to utilize specialized aids for plaque removal. Tooth brushing may be made easier by using a power-driven toothbrush or modifying a manual toothbrush. This can be accomplished by adding dimension to the handle with a ball, aluminum foil, or other comparable objects to compensate for the patient’s disability. (Examples are shown in Figure 4.) The multi-surface toothbrush may be beneficial for the older adult or caregiver. It easily adapts to both facial and lingual surfaces, which makes it both effective and less time consuming (Figure 3). Floss holders come in several varieties, and may be useful to assist persons with limited dexterity. They also may be helpful for the caregiver who is assisting the older adult with oral hygiene care. Though not a substitute for flossing, interproximal brushes also may make cleaning between teeth easier. Handles also can be modified on these adjuncts to enhance the grip. These brushes are particularly useful if there are spaces in between the teeth or if there are interproximal root surface defects.
Oral hygiene instruction should stress the importance of good oral health and the relationship of oral health to the older adult’s specific systemic health issues. Foods may taste better, halitosis may dissipate, and removable prostheses may fit better if the older adult takes the initiative towards improved oral hygiene. Quality of life can be a key motivating factor.
Effective
patient instruction
Educating
the older adult patient can prove challenging, especially if communication
is ineffective between the patient and caregiver. Introductions can be
very important in establishing a patient-provider relationship. The patient
should always be addressed by his or her last name, using the title most
preferred by the patient (i.e., Mr., Mrs., Miss, Ms., Dr., Father, Professor).59
The caregiver should only use the patient’s first name if instructed
to do so and refrain from using terminology, such as “dear”
or “honey,” due to condescending implications. Other areas
of consideration when conversing with older adults are vision and hearing
impairments, the patient’s tendency toward introspection, and slowing
of voluntary responses and thought associations.60
Patience is extremely important when working with an older adult exhibiting dementia. Older adults who are lonely often enjoy the interaction interaction with a health care provider. Patients should be afforded the time necessary to convey their thoughts. They may respond slower than those who are younger. The caregiver should convey an interest in the patient by being a good listener. The visually impaired patient should always wear his/her glasses during patient instruction. It may be beneficial to write down instructions for home care to eliminate confusion later. Large print and diagrams may help to reinforce instructions.
Establishing rapport with older adult patients may enhance their interest in improving their own oral health and that of their family members. Many older patients are grandparents and could act as prevention advocates. Older adults value their grandchildren and may be instrumental in passing on preventive behaviors that they may not have valued or practiced as a child themselves.61
Complete
or partial edentulism
Although more people of advanced years are retaining their teeth longer,
complete or partial edentulism still exists. Dentures are only 20% effective
in mastication compared to the natural dentition. When teeth are lost,
the vertical dimension of the face is reduced and wrinkles appear more
prominent. Often moisture forms in the deep folds at the commissures secondary
to this overclosure of the mouth. The commissures become fissured and
candida may develop. This is referred to as angular cheilosis
(Figure 7). An ill-fitting denture can cause resorption of the
alveolar ridge, irritation of the underlying adjacent tissue, ulcerations,
and fungal infections.5 Eating and communicating become difficult and
social withdrawal can occur.
Patients
with partial or complete removable dentures should be encouraged to take
them out at bedtime to rest the underlying tissues and prevent inflammation
or the formation of bacterial, fungal, or viral lesions/ulcerations. An
epulis or flange of tissue can form in response to denture irritation
(Figure 8). Infections should be treated based on the
organism identified, dentures should be adjusted when ill-fitting, and
oral hygiene must be stressed. Dental plaque should be removed from the
oral cavity and the denture to reduce the possibility of irritation and
infection
(Figure 9). Dentures should be soaked in tepid water
in a disposable container overnight. If a patient has an oral infection
such as candida, the denture can be soaked in an antibiotic rinse to prevent
reinfecting the mouth, while the patient is undergoing antifungal therapy.60
Dental examinations are encouraged for everyone including, the completely
edentulous patient. The completely edentulous patient should seek a dental
exam at least every year. This will allow for the assessment of dentures
and the oral cavity to be thoroughly examined.
Alternative treatments for missing teeth, include fixed prostheses and implants. In either of these modalities, optimum oral hygiene is imperative. Cost may be an issue for older adults since many do not have dental insurance and fees are paid out-of-pocket.44
Oral
cancer
Since the median age at diagnosis of oral cancer is 64,
it is necessary to educate the public about the factors contributing to
this disease, as well as the importance of routine oral examinations.44
Alcohol and tobacco use are major risk factors, and both seem to be potential
risk behaviors among the older adult population. Surveys conducted in
health care settings have found an increased prevalence of alcoholism
ranging from 6 to 20% among the older population in hospitals, nursing
homes, psychiatric wards, and emergency rooms.57
Cigarette, pipe, and cigar smoking are associated with squamous cell carcinoma;
90% of all oral carcinomas are of the squamous cell type. Smokeless (spit)
tobacco use is connected with verrucous carcinoma. Semi-annual or annual
intraoral and extraoral examinations are advised. Dental health care providers
must perform these assessment procedures at each patient visit to promote
early diagnosis, treatment, and cure.8
Only 52% of patients with oral cancer survive the five-year mark.44 By the time of diagnosis, many of these lesions have increased dramatically in size or have metastasized, resulting in a poor prognosis. Patients should be educated on the clinical signs of oral cancer and the technique for performing self-assessment. Areas most often affected by oral cancer are the lateral borders of the tongue and the floor of the mouth.8
The treatment of early oral cancers usually involves surgery, whereas more advanced lesions generally require a combination of surgery and radiation therapy.9 Oral complications from the treatment itself can include ulcerations; mucositis; bacterial, viral, and fungal infections; dysphagia; dysgeusia; xerostomia; rampant decay, particularly on the cervical third of the tooth; and osteoradionecrosis. The patient should be seen several weeks prior to the initiation of radiation to assess the hard and soft tissues of the oral cavity. All areas of potential infection should be cared for, such as periodontally involved or carious teeth, rough restorations, or ill-fitting appliances. Frequent recalls during and after therapy are advised. The fabrication of custom fluoride trays for daily use is an absolute necessity for the remainder of the patient’s life.34
