CE Course 11

Oral Health and Older Adults

Credit: Continuing Education Hours: 2
If you have specific questions about the CE requirements in your state, or if you're not sure if the course will be accepted, please consult your state dental board.

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Table of Contents


Course Goals

The purpose of this continuing education (CE) course is to provide a comprehensive overview of the health issues facing the aging population. Specific emphasis will be placed on identification and management of the oral health needs of the older adult. Physical, mental, and social issues affecting the oral health of the independent, homebound, and institutionalized older adults also will be discussed.


Learning Outcomes

Upon completion of this course, the participant will be able to:

  1. Define the current and projected demographics of the older adult population.
  2. Identify prescription drugs most frequently taken by the older adult and the associated oral implications.
  3. Discriminate between fact and fiction regarding the physiologic changes associated with aging.
  4. Describe common medical conditions experienced by the older adult, the appropriate medical management of these conditions, and the oral health considerations associated with each condition.
  5. Describe the relationship between nutrition and aging.
  6. Discuss common oral conditions observed in the older adult and their management.
  7. Discuss the impact of social issues and legislation on the oral health of the homebound and institutionalized older adult.
  8. Discuss the barriers that interfere with the oral health-seeking behaviors of the older adult.
  9. Incorporate positive staff attitudes and improved access and comfort for the older patient.
  10. Implement office policies that will accommodate the older adult patient.

Assessment Method: Post-test only

Abstract

The population of individuals aged 65 and older is growing dramatically and is expected to increase 126% by 2011, compared to only a 42% rise in the population of the United States as a whole. The fastest growing segment of the older adult population is persons aged 85 and older (Figure 1).1
Although many members of this generation lead healthy independent lives, the challenge faced by oral health care professionals is providing care to the chronically ill and/or homebound or institutionalized older adult, particularly the oldest old and those with limited finances.

Effective communication skills are essential when dealing with older adults and their families. Collaboration between medical/allied health professionals and oral health care professionals is also critical in order to accurately assess and manage the oral health needs of the aging patient. A preventive approach to oral health with sensitivity to the physical, mental, and social status of the patient is the focus of this course. Marketing strategies to alleviate common barriers to seeking oral health care among this age group are provided.


Key Terms

Adverse drug reaction
any response that is unintended and undesired and that occurs at doses normally used.

Ageism
negative attitudes or prejudice toward older persons

Agerasia
healthy and vigorous old age

Compliance
the extent to which a patient’s behavior coincides with a practitioner’s planned medical regimen.

Dysgeusia
altered taste involving both flavor and acuity

Dysphagia
difficulty swallowing

Hospice
an organization, independent or within an institution, that provides a centralized interdisciplinary program of supportive services to persons and their families seeking end of life care. These services can include palliative, pain management, pastoral care, social service resources, etc.

Hyperoralia
placing inappropriate objects in the mouth

Nocturia
excessive urination at night Polypharmacy taking 3 or more drugs daily Young old age 65 to 74

Old
age 75 to 84

Old old
age 85 and older.


Introduction

Based on current demographics, it is certain that dental hygienists will see an increased number of geriatric patients in their workplaces. Descriptive statistics about the older adult population can provide useful insight regarding their health knowledge, attitudes and behaviors, and the barriers that prevent them from seeking oral health care. Assessment and management of the oral conditions experienced by the older adult are complex, and the dental hygienist must be familiar with the physiologic, pathologic, pharmacologic, and psychosocial aspects of aging.


Demographics of the Older Adult

Adults aged 65 and older comprise 12.4% of the United States population. Females outnumber males, accounting for 7.3% of this population. The overall percentage of older adults is anticipated to increase dramatically over the next several years.2 The 2000 census revealed the most rapid increase in population growth was among 45 to 54 year olds. This 49% rise is primarily due to the aging of “baby boomers” (those born between 1946 and 1964).2

The U.S. Bureau of the Census 2000 Report made the following data available regarding older adults:1

  1. Seventy-four percent of the men were married in contrast to 43% of the women. Women were four times as likely to be widows than men. Eight percent of the older adult population were divorced or separated. Though this is a low percentage, it is significantly higher than the 1990 statistics.
  2. Fifty-five percent of independent older adults lived with their spouse and 30% lived alone. As age increases, the chance of living with a spouse decreases, particularly for women. Living arrangements also reflected those of a combined household with more than 1.1 million older adults living with their children and/or grandchildren. Approximately 4.5% of persons age 65 and older lived in nursing homes. Of those residing in nursing homes, 1.1% were 65 to 74 years old, 4.7% are 75 to 84 years old, and 18.2% were aged 85 and older.
  3. Approximately 16.4% of older adults in the United States in the year 2000 were minorities. The breakdown was 8.0% African American, 2.4% Asian or Pacific Islander, and less than 1% American Indian or Alaskan. Those of Hispanic origin comprised 5.6% of this population. Less than 1% of older adults reported to be of two or more races.
  4. Slightly more than half of the older adult population (52%) lived in nine states. Those states in descending order of population are California, Florida, New York, Texas, Pennsylvania, Ohio, Illinois, Michigan, and New Jersey. Seventy-seven percent of the older adults resided in metropolitan areas. Older adults resisted changing residence more than any other age group.
  5. The median income for those aged 65 and older in 2000 was $13,769. Males reported a median income of $19,168, while females reported $10,899 annually. The major source of income was social security. Other sources of income included earnings, assets, and pensions. Approximately 3.4 million older adults were below the poverty level in 2000.
  6. The educational level attained by the older adult is increasing. Between 1970 and 2000, the number of older adults who had completed high school increased from 28% to 70%. Approximately 16% of older adults hold a bachelor’s degree or higher.
  7. Many older adults expressed at least one chronic medical health problem and, consequently, many perceived themselves as being in fair or poor health. Many of these chronic illnesses manifest as physical or mental limitations. In the 64 to 74 year age group, 28.8% reported a limitation caused by a chronic condition, while 50.6% of those aged 75 and older reported similar disease-induced restrictions.


Dental Characteristics of the Older Adult

As the population matures, more older adults are retaining their teeth. Statistics show that nearly 40 years ago, 75% of those aged 75 and older were edentulous. Recent data suggests that no more than 40% of persons in this age group are edentulous.3 Although edentulism is less prevalent, overall there is still a high incidence in those of lower socioeconomic status. People with incomes below the poverty level were twice as. likely to be edentulous. In addition, edentulism is higher among African Americans than Caucasians. Geography also plays a role in edentulism statistics. States such as Hawaii, California, and Oregon report a tooth loss rate of 14 to 16%; however, in states such as Kentucky and West Virginia the tooth loss rate is as high as 44 to 48%.4

When oral health care is neglected, many older adults face various problems, such as oral pain that can affect their quality of life and cause them to withdraw socially. Oral pain can lead to more severe dental and systemic problems by compromising nutritional intake. Research shows there is a correlation between racial/ethnic background and level of education and seeking help for oral pain. Older Caucasian adults with a higher level of education were less likely to report oral pain than those from other racial/ethnic backgrounds and lower educational levels.4

The most significant risk for tooth loss in older adults is dental caries, in particular, root caries. Males are more affected by root caries than females and it most commonly occurs in the molar teeth. Other risk factors include low socioeconomic status, previous tooth loss, poor oral hygiene, and inadequate dentalseeking behaviors. Xerostomia, fixed or removable partials, abrasions at the cementoenamel junction, and diets composed of soft, sticky and/or sugary foods are also
contributing factors to root caries.4

Periodontal disease is another area of concern in the older adult population. Studies have reported that 40% of ambulatory older adults have gingivitis, while 33 to 60% have some degree of periodontal destruction.5

Approximately 15,000 older adults are affected each year by oral cancer. The Centers for Disease Control and Prevention (CDC) report that oral cancer is responsible for nearly 8,000 deaths each year. More than half of these deaths occur among those aged 65 and older.4


Physiological Changes of Aging

Agerasia, or healthy and vigorous old age, is not a very familiar term. This may be due to the fact that old age has not been traditionally revered by our society and many depict aging as anything but a healthy and vigorous stage of life. Although disease and impaired function are not an inevitable consequence of the aging process, there are certain systemic and oral physiological changes that are a factual part of growing older.

Systemic
Illness and aging are not always related. However, due to a reduction in cells and a decreased metabolism, the aging body tends to work less efficiently. As a result, homeostasis, immunity, and the ability to withstand stress become impaired.

The skin is one of the most noticeable areas indicative of aging. Lines appear in the face, particularly around the eyes, nose, and mouth. This is due to subcutaneous fat loss, dermal thinning, decreasing collagen and elastin, and a 50% decline in cell replacement. Inevitably, with the reduction of cell replacement in the skin, the person may be more prone to infection since wounds may heal more slowly. Another aging characteristic is that the skin takes on an almost transparent appearance as it loses elasticity. Brown spots appear in areas exposed to the sun due to localized melanocyte proliferation. However, overall melanocyte production decreases in the aging process. Body temperature also becomes difficult to regulate as a result of the decrease in size, number, and function of sweat glands and the loss of subcutaneous fat.6,7

Hair, nails, vision, and hearing are also targets of the aging process. Hair loses its pigmentation and takes on a gray or white appearance and often becomes thinner. The nails exhibit more brittleness, longitudinal ridges, and may have malformations. Aesthetic changes occur in the eye area. The eyes rest deeper in the sockets, eyelids lose their elasticity, the cornea flattens, the pigmentation of the iris becomes irregular or fades, and fatty deposits may form under a thinning yellow conjunctiva. Due to the size reduction of the pupil, the older adult needs about three times as much light as a younger person to see objects clearly. Therefore, night vision and depth perception are weakened. Color vision, especially to hues of blue to green, is also affected due to weakening in cones in the retina. Cataracts (an opacity of the lens) are common in persons aged 65 and older. Possible etiologies include diabetes, retinal detachment, glaucoma, chemical changes in lens proteins, etc. Changes also emerge in the older adult’s hearing. The extent of hearing loss varies with each individual. Before a person reaches young-old status around the age of 60, they may experience difficulty hearing high-pitched sounds, especially the consonants s,z,t,f, and g.6-8

The progression of age also causes some changes to occur in the respiratory, cardiovascular, gastrointestinal, renal, neurological, musculoskeletal, immune, and endocrine systems. There is a decrease in pulmonary function due to respiratory muscle degeneration and a reduction in ventilatory capacity. The lungs exhibit more rigidity, and the size of the alveoli declines. Respiratory fluids decrease by 30%; therefore the risk for pulmonary infection and mucous plugs increases.6,9,10

The size of the heart may become slightly smaller, thereby losing its contractile strength and efficiency. It has been reported that cardiac output at rest in an individual of 70 years old decreases by as much as 30 to 35%.6 Stress also can have a deleterious effect on the older person’s heart, and it may take the heart rate longer to regulate following exercise.6,11

There is a reduction in the mucosal elasticity and secretions of the gastrointestinal system. This, in addition to medications, can contribute to a loss of appetite and constipation. Additionally, there is less efficient metabolism and detoxification of drugs by the liver.6,12

Other age-related changes occur in the renal system. Overall, kidney function may diminish starting as early as age 40. The size of the kidney and bladder decrease, and there is an impaired renal clearance of drugs. There is also reduction in the ability for the renal system to respond to sodium uptake. Typically, there is an increase in residual urine, frequency, and nocturia in the older adult.6

Nerve transmission slows down in the older adult person; therefore the reaction time to external stimuli is slower and there is an increase in the pain threshold. The older adult may need to rest more during the day, since sleep patterns become more irregular and frequent awakenings occur.6

Changes observed in the musculoskeletal, immune, and endocrine systems are characterized by a decrease in height, bone mass, muscle mass, and collagen formation. Less elasticity in the joints and supporting structures tend to be evident. Walking may prove difficult for some older adults. In order to compensate, the person may walk by taking shorter steps and stand with legs spread for balance.6

As age increases, so does the incidence of autoimmune disease. The body’s ability to recognize host cells and detect and destroy antigens and mutant cells becomes difficult. Susceptibility to infection increases since there is a decreased antibody response. The absorption of vitamin B12 may decline resulting in reduced erythrocyte mass and a decrease in hemoglobin and hematocrit.6,13

Lastly, age progression affects the endocrine system. Most notably, there is a diminished ability for the body to tolerate stress. This is evident in the production of glucose. In response to stress, the blood glucose level rises and regulation is impaired, increasing the risk of diabetes.6,9

Oral
Myths related to changes in the oral cavity associated with aging are no longer as widely accepted as they were 10 to 20 years ago. For instance, the myth that most older adults will lose their teeth was a common misconception about age progression. As mentioned previously, a greater percentage of the older adult population are retaining their natural teeth, thereby reducing the need for complete or partial prostheses. Another myth that still exists to some degree is that dry mouth is a normal consequence of growing old. In healthy adults, changes in salivary composition and flow are minimal to nonexistent. Dry mouth is usually disease or medication-induced.

Specific alterations in the oral soft and hard tissues can occur later in life. Oral soft tissues exhibit some of the same changes as the skin. There is a loss of elasticity and the tissues tend to become thinner and less vascular. The lips can be dry, and the oral mucosa and tongue may appear smooth and shiny due to their thinner nature and the existence of nutritional deficiencies. The capillaries are more fragile; therefore petechiae on the mucosa occur more frequently. Evidence of hyperkeratosis may be evident from broken teeth, restorations, ill-fitting dentures, or tobacco use. Often the tongue becomes fissured and sublingual varicosities may present that appear as deep, red, or bluish nodular dilated vessels on either side of the midline on the ventral surface of the tongue and the floor of the mouth.14

The older adult commonly displays gingival recession. However, this may be the result of prior disease, insufficient attached gingiva, or malpositioned teeth. An increase in the thickness in cementum can also be observed. Color changes in the teeth may arise from the long-term intake of food with coloring agents or from prolonged tobacco use. Occlusal or incisal attrition may be derived from long-term dietary habits, occupational factors, or bruxism. Teeth that display attrition may be more brittle and prone to chipping.15


Common Medical Conditions


The majority of older adults exhibit at least one medical problem. Disabilities associated with chronic illness increase sharply with advancing age (Figure 2).2 As individuals grow older, their physiologic functions decline, making them more susceptible to stress and infection and less able to perform activities of daily living (ADL).2 These factors are largely responsible for the spread of disease, particularly among institutionalized older adults.16 The medical conditions most frequently encountered by the older adult include cardiovascular disease, osteoarthritis and osteoporosis, dementia, depression, diabetes, and sensory deficits.

The oral status of medically compromised older adults is largely the result of a combination of local and systemic factors. Poor oral health can exacerbate a medical condition, cause pain or discomfort, alter nutrition, and decrease a person’s self-esteem.


Cardiovascular Disease

Cardiovascular disease is the number one cause of mortality in the older adult population. Physiologic cellular and tissue changes during aging such as decreased cardiac muscle strength, increased amounts of fat, and a reduction in the number of normal functioning cells require the heart to work harder to adequately oxygenate the blood. The heart muscle may become stiff due to an increase in connective tissue and ventricular hypertrophy.17 Conditions such as hypertension, valvular disease, and anemia are further complicated by these changes. Ventricular arrhythmias are relatively common in older adults and often require a pacemaker. The prevalence of atrial fibrillation also increases with age and raises the older adult’s risk of developing congestive heart failure (CHF) and stroke.18

CHF usually begins with a weakening of the left ventricle. If the left ventricle fails, blood cannot be forced out into the systemic circulation. An accumulation of blood in the pulmonary vessels results. This condition is referred to as pulmonary edema. Consequently, the right ventricle becomes overworked to compensate for the back flow of blood from the lungs. The right stasis of blood often leads to systemic edema manifested as pitting edema of the extremities such as swollen ankles, for example. Medical management of CHF includes weight control and a reduction in sodium intake; limited exertion; and drugs such as ACE inhibitors, diuretics, glycosides, vasodilators, and long-acting nitrates.9

When a patient exhibits atherosclerosis (the deposition of fatty plaques in the coronary vessels), the lumen of the vessel is narrowed, further impeding blood flow. Both angina pectoris and myocardial infarction can manifest as a result of the heart being deprived of oxygen. The treatment of angina typically involves a low-fat, cholesterol and sodium diet; exercise; smoking cessation, if applicable; and drugs such as nitrates, calcium channel blockers, platelet aggregation inhibitors, and ß-adrenergic blocking agents.9,19

Stroke or cerebrovascular accident (CVA) also may result from impaired oxygenation. The risk factors for stroke include previous stroke or transient ischemic attack (TIA), hypertension, atherosclerosis, cardiac abnormalities, erythrocytosis, diabetes mellitus, periodontal disease, elevated blood lipids, tobacco, alcohol or drug abuse, stress, or inactivity.20-27 Hypertension is managed with antihypertensive drugs such as ACE inhibitors; calcium channel blockers; loop diuretics; and a reduction in weight, sodium, stress, and smoking, if applicable.28 The medical management of stroke may involve surgery (particularly if carotid vessel calcifications are present); physical and occupational therapy; and drugs such as anticoagulants, antihypertensives, thrombolytics, vasodilators, and steroids. The major cause of death among stroke survivors is myocardial infarction.29

Dental patients with cardiovascular complications such as a history of hypertension, stroke, congestive heart failure, angina, or myocardial infarction require discretion when administering a local anesthetic. Strong vasopressors should be avoided and dosages should be adjusted for such patients. These conditions do not require antibiotic prophylaxis prior to dental procedures. The blood pressure should be monitored at each visit and long-term administration of nonsteroidal anti-inflammatory drugs (NSAIDs) by the dentist should be avoided, because they are known to decrease the activity of many antihypertensive drugs. Aspirin, NSAIDs, and certain herbs potentiate the effects of anticoagulants. Drugs used in the treatment of cardiovascular disease should be assessed and managed for druginduced oral side effects, particularly xerostomia that places the patient at a higher risk for caries and periodontal disease.9,30

Prothrombin levels and the international normalized ratio (INR) should also be monitored for all patients taking anticoagulants; a patient should not be treated if the INR exceeds 3.0 or the prothrombin time (PT) is greater than 1.5 times the normal control value.9 Additional factors to consider when caring for these patients should include chair positioning (semi-supine); length of appointments (brief, midmorning); physical limitations (paralysis, mobility needs, poor manual dexterity, fatigue with limited exertion, dysphagia, sensory deficits); impaired mental functioning (slow, poor memory, speech and vision difficulties, loss of initiative, increased sensitivity to pain and touch); and the existence of anxiety or depression.30


Dementia

Although dementia normally occurs later in life, it is not a normal consequence of aging. Less than 10% of persons aged 65 and older are affected, while 25 to 50% of those aged 85 and older acquire this condition.31 The most common form of dementia is Alzheimer’s disease. Other disorders that may exhibit dementia because they destroy brain cells include Parkinson’s and Huntington’s Huntington’s diseases. Vascular dementia results from a disruption of blood flow to the brain caused by stroke. Dementia caused by depression, alcoholism, drug interactions, head injuries, infections (AIDS, meningitis, syphilis), brain tumors, nutritional deficiencies and thyroid problems can be reversed if treated early. Dementia attributed to dental restorations or aluminum is unfounded.6,31

All forms of dementia exhibit major impairments in recent memory, comprehension, judgment, orientation to time, people and places, attention span, and an inability to think abstractly. Agitation, anxiety, delusions, paranoia, and hallucinations are also common signs of dementia.32

Presently there is no cure for Alzheimer’s disease. Four cholinesterase inhibitor drugs are used in the treatment of this condition. They are Cognex®, Aricept®, Exelon®, and Reminyl®. The mechanism of action of these drugs is to prevent the breakdown of acetylcholine in the brain.

Alzheimer’s disease can progress at varying rates. The duration of the disease may range from 3 to 20 years and usually progresses through stages that begin with impaired memory and cognitive skills. Eventually the individual requires complete care.32 (See Table I for a simplistic description of these stages.6,33) Subtle changes can be observed in the subdivision of these stages based on the source.

Dental intervention should begin early in the disease process. Neglect for personal hygiene is often one of the initial signs. The dental hygienist should address patients by a favorite name and should speak using simple words and short sentences in a soothing, clear voice. If the patient appears agitated, it is always best for the caregiver to redirect his or her attention to something else, rather than argue or try to reason with him or her.31 Often the agitation is associated with a change in environment or caregiver. Therefore, it may be advisable for the dental hygienist to see the patient at his or her home or living facility, if feasible. It is important for the dental hygienist to simplify oral hygiene tasks so the patient successfully incorporates these tasks into the daily routine. The dental hygienist should give the patient a toothbrush to hold on to with one or both hands. Eye contact should be maintained during instruction by the caregiver and distracting noises should be kept to a minimum.

The health care provider must work quickly and mouth props and restraining devices (physical/chemical) may be necessary to stabilize the patient and facilitate treatment. Druginduced tardive dyskinesia (central nervous system disorder causing facial distortions) may make oral hygiene treatment a greater challenge.34 Caregivers should set a specific time of day for oral care and play the same music each time to cue the patient to enter the bathroom and sit by the sink, so the oral care regimen can begin.3 Mouth props, antimicrobial rinse, multi-surface toothbrushes, and fluoride are essential for optimal homecare (Figure 3).35


Depression

Depression can affect older adults as they try—and experience different levels of success—in adjusting to major lifestyle changes such as loss of a loved one, separation from career and children, loss of independence, loneliness, and chronic illness. Depression is characterized by a sad demeanor with a lack of interest in normal daily activities. Many older adults become obsessed with physical pain and discomfort rather than appearing sad. Loss of appetite or excessive consumption of carbohydrates and salty foods, fatigue, slowed responses, hopelessness, lack of self-worth, and preoccupation with death also are indicative of depression.36

The most effective treatment appears to be the combination of psychotherapy and medication. Common drugs administered for depression include Paxil®, Zoloft®, Elavil®, Prozac®, Effexor®, and Remeron®. Caution should be exercised when administering local anesthetics; the lowest concentration of epinephrine is advised. Demerol is contraindicated in persons taking monoamine oxidase (MAO) inhibitors. Orthostatic hypotension is a common side effect of antidepressants, and patients should remain upright in the dental chair for several minutes before rising to leave.37

The dental hygienist may be the first person to notice signs of early depression because many older adults live alone and experience very little interaction with others. Areferral for psychological consultation is recommended prior to oral health treatment. Preventive measures include the assessment and management of intraoral associated signs of depression such as hyposalivation leading to dysphagia, caries, periodontal disease, burning mouth, candida, inability to tolerate prostheses, fissuring of the tongue and lips; temporomandibular joint (TMJ) and facial pain; and drug-induced xerostomia and bruxism. Early intervention including frequent recalls, diet counseling, suggesting the use of artificial salivas and topical fluorides, offering oral lubricants and toothpastes formulated to relieve the symptoms of dry mouth, and supportive assistance are important to the overall success of the oral treatment plan.38


Osteoarthritis

Osteoarthritis is the most common form of arthritis. It is classified as a noninflammatory type of joint destruction primarily affecting the large joints. The incidence of osteoarthritis increases with age and almost all persons over the age of 70 have some form of the disease.39 Treatment may range from simple monitoring of the disease without treatment to NSAIDs (i.e., Celebrex® and Vioxx®), hot/cold compresses, periods of rest and exercise, walking aids/braces, and artificial joint replacement surgery.40

Dental considerations include monitoring the risks of gastrointestinal bleeding associated with the use of Celebrex and aspirin, or prolonged bleeding with either Celebrex or Vioxx when taken with Coumadin™. Vioxx is also given for acute oral health pain.40,41 Prosthetic joints require antibiotic premedication before oral health treatment if the replacement occurred two years or less prior to the appointment or if the patient exhibits uncontrolled insulindependent diabetes, hemophilia, rheumatoid arthritis, lupus, or any other immune-compromising condition with a reduced capacity to resist infection. Pins, screws, and plates do not require premedication.42 Efforts should be made to keep the patient comfortable during the appointment. The waiting room and operatory should be climate-controlled to alleviate joint stiffness. Moist heat is recommended to reduce TMJ pain, and the use of a mouth prop during treatment is advised to prevent fatigue associated with trying to keep the mouth open. Short appointments, supporting affected joints, and allowing the patient to change positions frequently will enhance comfort. If manual dexterity is compromised, a power-driven toothbrush, floss holder, or a tailored toothbrush modified to meet the patient’s individual needs are suggested34 (Figure 4).


Osteoporosis

Oral and systemic loss of bone mass is often associated with aging, particularly in postmenopausal women. Osteoporosis can manifest as fractures, especially of the spine and hip, curvature of the spine, and a loss of height.43

Resorption of the alveolar bone may result in tooth loss.44 A combination of local factors, such as plaque with systemic osteoporosis, may exacerbate alveolar bone loss. Treatment usually entails the administration of calcium, vitamin D supplements, supplements, hormone replacement, and/or biphosphonate therapy.45 Fosamax® and Actonel® are the only biphosphonate drugs accepted for use in the United States for the treatment of osteoporosis. Evista®, a selective estrogen receptor, also increases bone mineral density.46 Changes observed in the alveolar bone by routine evaluation utilizing radiographs and periodontal assessments of probing depth and mobility may identify early signs of osteoporosis.44


Diabetes

The majority of diabetics diagnosed in the United States have type 2 or non-insulin dependent diabetes mellitus (NIDDM). Type 2 diabetes has the highest rate of co-morbidity with coronary artery disease, hypertension, and osteoarthritis among older adults.17 It is one of the most common systemic diseases in older adults encountered by oral health practitioners. This condition has a late onset clinically and usually affects adults aged 40 and older who are obese. Oral hypoglycemic agents and diet modifications are used to manage the disease.9

It has been shown that diabetics under poor glycemic control have an increased risk and severity of periodontal disease.47-49 Conversely, periodontal infections can cause blood glucose levels to rise, making the management of diabetes difficult. Glycemic control can be determined by asking a patient how often the blood glucose level is monitored, what technique is used for monitoring, what forms of treatment have been prescribed, and how compliant the patient is with taking medications and adhering to his/her diet restrictions. The health of the oral soft tissues is also indicative of glycemic control. Uncontrolled diabetes may be characterized by dry cracked lips, xerostomia, parotid gland enlargement, burning inflamed mucosa, gingival edema and bleeding, poor wound healing, candidiasis, periodontal abscesses, significant probing depths, and neuropathy. Research findings also suggest that older adults with diabetes exhibit a higher rate of dental caries and tooth loss than non-diabetics of the same age group.50 Frequent recall examinations, periodontal debridement, meticulous home care—including the use of fluoride and oral lubricants and toothpastes formulated to reduce the total microbial flora in the mouth—and systemic control of blood glucose levels are critical to maintaining optimal oral health.


Sensory deficits

Vision and hearing changes are very common among older adults. Approximately one-third of persons aged 65 and older have hearing impairments, and 30% of those individuals are deaf in at least one ear. Most older adults experience presbycusis or a progressive bilateral inability to hear high frequency tones (above 4000 Hz) or in some cases, the loss of ability to comprehend speech (300 to 2000 Hz). Presbycusis appears to be related to external factors such as working in factories or living in large cities. Tinnitus, or ringing of the ears, also is prevalent with advancing age and is particularly acute in quiet surroundings.8,32

Visual disturbances include a decline in accommodation (ability to focus from near to far), cataracts, alterations in color and distance/depth, and limited ability to adjust from light to dark. More than half of the individuals termed legally blind are aged 60 and older and macular degeneration is the most common cause. The most common type of cataract is related to aging, and more than half of Americans age 65 and older have a cataract.32,51

The oral health care provider must be cognizant of any sensory impairments to ensure effective communication. Most forms of hearing loss occur gradually and patients often read lips to compensate. A thorough medical history is essential and aids in the development of creative ways to instruct the patient to enhance complete comprehension. The caregiver should appeal to the patient’s other senses as much as possible. If the patient is hearing impaired, the caregiver should face the patient, remove his/her face mask, speak normally, pause frequently—particularly when giving instructions—and never sit in front of a window or bright light that may cast a shadow on his/her face. Apencil and paper can also be used to communicate and send home instructions. Background noises can disturb a patient wearing a hearing aid. Therefore, it is recommended that the dental hygienist ask the patient to turn off a hearing aid when using high-pitched powered scaling and toothbrush devices. Caregivers should learn some common signs for “open,” “close,”“rinse,” and “tell, show, do” to reinforce all procedures performed and to prevent confusion.34

Certain guidelines should be followed when treating a patient with vision impairments. The caregiver should lead the patient to the operatory by standing slightly in front; the patient will grasp the caregiver’s bent arm near the elbow for guidance. The patient should always be informed about changes in floor textures, steps, and so forth. The path also should be kept free of obstacles. Loud noises should be avoided when treating a patient with a vision impairment. The caregiver also should notify the patient when approaching him/her or exiting the room to prevent startling or embarrassing the patient. Procedures should be described by the caregiver in a step-by-step fashion and the patient’s own mouth can be utilized to provide oral hygiene instructions. If a guide dog accompanies the patient, office personnel should not distract the dog. The dog should be permitted to sit in the corner of the operatory until the appointment is concluded.34


Pharmacology and Aging

Commonly used drugs
Trends in pharmaceutical sales reflect the management of chronic illnesses in an aging population. More than three billion prescriptions were dispensed in 2001. Six of the top 10 drugs prescribed in 2001 were used to treat age-related chronic conditions such as cardiovascular disease, pain associated with arthritis, depression, and postmenopausal hormone replacement. Oral complications associated with these and many other prescription medications are extremely common (Table 2).52

Xerostomia, the most common drug-induced oral side effect, is associated with approximately 600 different prescription and over-thecounter (OTC) preparations in 26 different categories (Table 3).53 Xerostomia is not an inevitable result of aging.54 If medications are the etiology, consultation with the person’s physician is warranted to determine if there are alternatives that do not produce oral dryness. Drugs that produce xerostomia increase a person’s risk of developing dental caries. The potential for developing rampant decay is great in individuals who experience both drug-induced vomiting and xerostomia. A daily fluoride regimen in custom trays is advised for such patients.34

Adverse drug reactions
The incidence of adverse drug reactions in older adults is two to three times higher than in young adults. Adverse drug reactions are common in older adults due to the physiological changes that occur with aging, the diseases they experience, and changes in their diet.55 Common gastrointestinal changes that lead to the malabsorption of drugs include delayed gastric emptying, reduced visceral blood flow, decreased intestinal motility, and increased transit time. Changes in hepatic and renal function serve to reduce drug metabolism and excretion. Changes in body mass, such as increased adipose tissue and loss of skeletal muscle, can affect the storage of drugs.9 Poor nutrition, common in older adults, also increases the potential for adverse drug reactions. Drugs may increase the need for certain nutrients by increasing metabolism and competing for certain receptor sites. Many drugs must be taken with food or should not be taken with milk or grapefruit juice. The dental hygienist can alert a patient about potential adverse drug reactions and how to prevent them.

Drugs frequently associated with adverse reactions in older adults include NSAIDs, digoxin, systemic corticosteroids, diuretics, betablockers, methyldopa, clonidine, benzodiazepines, and calcium channel blockers. The adverse conditions associated with these drugs are delirium, falls, depression, urinary incontinence, and constipation.12,56

Polypharmacy issues
The older adult consumes approximately one-third of all prescription and OTC drugs. The average person aged 65 and older takes three or more medications daily and nearly 14 different prescriptions per year.56 Polypharmacy is an additional contributing factor to adverse drug reactions. Many older adults lack understanding due to a cognitive, sensory, or functional impairment or have not been properly educated by their health care providers about the negative outcomes of drug interactions related to poor compliance with a regimen and the impact of OTC drugs with their prescribed medications.6

Older adult patients who become confused when several drugs with various dosages often do not follow drug regimens. Other issues related to non-compliance include the belief that medications should only be taken as needed to relieve symptoms or financial constraints. As the number of prescribed medications increases, compliance with taking these medications tends to decrease. Polypharmacy increases the likelihood of drug interactions. Therefore, adverse drug reactions are the most common reason for hospital admissions among older adults. To further complicate matters, many OTC drugs (i.e., analgesics, antacids, and antihistamines), herbs, and vitamin/nutritional supplements are not viewed as medicines by the patient and are not reported to health care professionals during history-taking. With this in mind, it is essential to ask patients what medications they are taking in each of these categories.6,56

Adverse reactions also can occur when an individual sees multiple physicians and receives multiple drugs for the same medical condition or takes multiple medications from more than one pharmacy. Lastly, adverse drug reactions are likely if a person abuses alcohol.57


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 2. 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


Nutrition and Aging

The diet of older adults can be influenced by a variety of factors. Generally, older adults have reduced caloric requirements. One may either eat less or thrive on more foods with lower nutritional value.34 Gustatory and olfactory acuity may be diminished, making foods less appealing because they do not taste or smell as they once did. There may be oral health problems, such as a poor dentition, ill-fitting dentures, or periodontal disease that makes chewing more difficult. Impaired motor abilities can make getting to the grocery store, meal preparation, or feeding oneself complicated. Medications and disease can affect appetite and gastrointestinal motility. Many times older adults are on fixed incomes and may choose foods that cost less and are easy to prepare and potentially less nutritious. Older adults who live alone may not eat regularly or healthfully.34

When a diet is not well balanced, nutritional deficiencies can occur. Softer foods may be chosen when chewing function is impaired due to one or more oral health problems. This usually results in decreased protein consumption that can contribute to a zinc deficiency. The older adult must have an adequate amount of fluids, or cardiac function and/or dehydration can result. Many times dehydration causes confusion in the older adult. Many may not get sufficient exposure to sunlight, leading to a reduced synthesis of vitamin D in their skin. Calcium levels may fall due to medications, a reduced consumption of dairy products, limited physical activity, combined use of alcohol and antacids, and hormonal factors. Deficiencies in vitamin B complex, vitamin C, and folic acid are also common among older adults. Pernicious anemia is most frequently seen in the older population as a result of malabsorption of vitamin B12.62 Oral symptoms associated with this and other deficiencies are listed in Table 4.34

Nutritional counseling for the older adult is of utmost importance. Some older adults may not be aware of healthful nutritional habits and the probability that they could enhance their quality of life by the foods they eat. Nutrition for older adults should focus on preventing diseases such as atherosclerosis, anemias, osteoporosis, and dental caries. With nutritional guidance, an older adult should be able to make a connection between dietary deficiencies and lowered resistance to disease and premature aging.60 Nutritional counseling should not only provide the older adult with helpful dietary suggestions, but it also should be an opportunity for dental hygienists to become familiar with a patient’s way of life.

Nutritional intake is usually considered to be synonymous with oral food and fluid intake. However, that is not always possible, especially for institutionalized dependent older adults in a hospital or hospice setting. Upon proper consent, enteral nutrition may be initiated if oral intake is not possible after three to five days and the gastrointestinal tract is functional. This type of feeding is considered advantageous because it is more cost effective, fewer complications arise, GI mucosal integrity is maintained, and both the patient and caregiver can easily care for the external stoma.34 The patient and caregivers need to know that daily oral plaque control measures must be performed because bacteria continues to colonize even in the absence of food intake.34


Barriers to Seeking Oral Health Care

The older adult population is more likely to have chronic conditions that may affect their oral health, but they are less likely to visit an oral health care provider than younger adults.44,61 Chronic health conditions can inhibit older adults from seeking oral health care because such health conditions take precedence. The health care team should work together to help patients understand that oral health can affect overall health and that many chronic health conditions display secondary oral manifestations. In addition, chronic health conditions and physical impairments may keep the older adult from being able to get to the dental office. They may not be ambulatory or they must rely on others to transport them or utilize public transportation. Older adults may feel burdensome to others if they ask for help and may find public transportation confusing or intimidating. Those with impaired vision or literacy problems may have difficulty reading transportation schedules or the phone book. Older adults confined to wheelchairs may have difficulty obtaining transportation to and from the dental office. Likewise, patients unable to be transferred from their wheelchair to the dental chair may require special accommodations not available in many dental offices.61

Cost of dental services is another consideration. Most people with dental insurance utilize dental services. However, when persons retire they tend to lose their dental insurance coverage.44 Medicaid provides limited coverage for routine oral health care for low income and disabled older adults, and Medicare does not cover routine oral health care at all. Therefore, most dental care expenses are out-of-pocket for the older adult. This can be very challenging for those on a fixed income; consequently dental care is not used.61 People of all ages fear dental visits. However, older adults may compound their fear with worry about what they may encounter. Patients who are visually and/or hearing impaired may find communication with office personnel and practitioners too challenging. In addition, they may feel that their chronic health conditions will interfere with dental treatment.61

Attitudes and beliefs also can influence obtaining oral health care.61 Many of the old and old-old age groups (see key terms) still believe that losing one’s teeth is a part of the aging process and, therefore, they do not seek oral health treatment. People from other cultures may view the close proximity of the oral health care professional to patient as an invasion of privacy. This feeling of uneasiness could deter them from seeking treatment. Oral health care professionals also may exhibit ageism. They may feel that assessing the older adult patient takes too much time or in a person of advanced age, extensive treatment planning would be a disservice rather than a service. They also may be uncomfortable around older adult patients due to personal issues about getting older. These attitudes must change. Oral health care professionals need to become more familiar with older adult patients and their oral health needs. Communication skills must be improved to insure positive relationships between provider and patient.61


Accommodating the Older Adult in the Oral Health Care Setting

Currently, seniors account for almost half of the total consumer demand for services. More than three-fourths of all assets in the United States are owned by persons aged 55 and older. The senior market is subdivided by age (younger than 65 and 65 or older); economic circumstances (working, retired with a fixed income, and comfortable or wealthy retired); level of activity (sedentary or active, and traveler or stay-at-home); and so forth. Marketing strategies are based on these factors. Seniors may experience physical limitations such as wheelchair dependency or vision impairment. The key to marketing is not to ignore that segment of society, but to adjust the marketing strategy to meet their needs. As the “baby boomers” are quickly approaching senior status, the markets are becoming more serviceoriented; health and fitness have become increasingly important to older adults. Consequently, seniors are seeking oral health care at a greater rate than ever before, but these visits vary based on race, level of education attained, and the existence of natural teeth.63

Office design
The dental office should include design features that consider the unique needs of older patients. The entire office should be climate controlled. controlled. If that is not feasible, light blankets should be made available in the operatories. If there is music, it should be pleasing and low volume. The waiting room should have good lighting and the reading materials should include large print selections as well as periodicals that are of interest to older adults. Chairs should be supportive and stationary to facilitate seating and rising. Loose rugs or mats and highly waxed floors should be avoided to prevent tripping or falling. Highly waxed floors can cause slipping and adversely affect sight in persons with vision problems.63

Entrances, doorways, restrooms, and operatories must be accessible to the disabled. The dental chair itself should possess a double-articulating headrest to permit adjustment of both the head and back. Pillows also should be made available to support the patient’s potentially painful muscles and joints. Hoses and foot petals should be neatly secured and out of the line of traffic.63

Staff behaviors
Respect for older adults by office staff is crucial to helping the elderly feel welcome.63 Numerous studies conducted to assess health care provider attitudes toward treating older adults revealed ageist attitudes that stemmed from a lack of knowledge and experience working with older adults, concern that older adults were too chronically ill or too old to treat optimally, and exposure to older adult patients on public assistance who could not pay for treatment rendered. Unfortunately, many of these attitudes do not appear to be changing.64,65 It is the responsibility of dental and dental hygiene educational programs to provide learning experiences that prepare practitioners to be competent and comfortable in assessing and managing the needs of older adults. Increasing reimbursement rates and expanding dental services through Medicaid is also critical to addressing this problem.66

Respect and awareness of the complex needs of older adults by all practitioners in the office is critical.63 The office manager should be knowledgeable about how to effectively communicate with older adults, particularly if hearing or vision impairment exists. In addition, the office manager must be able to offer creative and flexible financing options, such as senior discounts, since the vast majority of oral health care services received by older adults are out-of-pocket expenses. Familiarity with when to involve a patient’s family members or caregivers in scheduling or completing transactions is also important.

The dentist, dental hygienist, and dental assistant must be trained and able to assist the patient in wheelchair transfers. Certification in cardiopulmonary resuscitation and thorough reviews of the medical history must occur at each appointment to reduce the risk of medical emergencies. Simple courtesies such as recommending recommending patients taking diuretics use the restroom before going back to the operatory or suggesting patients stay seated for several minutes prior to rising from a supine position are important, too. Sending birthday cards, reminders for recall, and informational pamphlets about oral and systemic health to patients is advised, because older adults usually enjoy reading and appreciate the personal interest that has been taken in them. Oral cancer screenings and free dental consultations at local senior centers prove rewarding, while still reaching a broader segment of the older adult population.67


The Homebound/ Institutionalized Older Adult

Many older adults with mild to severe functional limitations can continue to live at home with the cooperation and support of family, friends, and programs such as home health, and hospice. These homebound individuals often require a dentist to make house calls or they must be brought to a hospital-based dental facility via an ambulance or other transportation system. Mobile dental units and laws that, in some states, permit the dental hygienist to provide care to the homebound or the residents of long-term care facilities offer more options for these individuals.68 In a series of studies of long-term care facilities cited in Oral Health in America: A Report of the Surgeon General, 45 to 65% of institutionalized older adult residents surveyed were completely edentulous.44 Many of the residents with or without teeth required immediate care. The literature is replete with evidence that suggests oral care in long-term care facilities is poor at best. In a 1994 Home Health and Hospice survey, only 1% of patients reported receiving oral care.21 Older adult recipients of long-term care are receiving minimal assistance with their oral care despite their needs and limitations.69

It is important to keep in mind that as greater numbers of chronically ill, dentate older adults from the baby boomer generation enter long-term care facilities, the need for oral health care services will increase and become more of a public health issue.70


Legislation

The federal Omnibus Reconciliation Act of 1987 (OBRA) established some specific requirements for dental services in more than 20,000 nursing homes across the country. The Health Care Financing Administration (HCFA) mandated that all nursing homes receiving Medicaid and Medicare reimbursements provide routine and emergency oral health care to their residents.71 These regulations were effective on April 1, 1992 and specifically required long-term care facilities to 1) assist patients in obtaining routine and emergency dental care; 2) provide dental care internally or obtain this care from an external source for each resident; 3) assist in scheduling appointments for dental care and arrange transportation to the dentist; and 4) develop an oral health program that includes annual staff in-service training, an oral examination within 45 days of admission that is repeated annually for each resident, and a daily oral hygiene preventive care plan for each resident. Each facility should have an agreement with a dentist to deliver oral health care services and make referrals.72 Visits to the nursing home to assess residents’ needs and provide care can be accomplished bedside for the totally dependent patient or in an area designated for oral health care, with mobile equipment for those who are ambulatory (Figure 10).


Oral Health Concerns

Appearance is important to people of all age groups, and older adults are no exception. Many older adults report that a clean mouth makes them feel healthier, look better, and feel more comfortable.69 Since many individuals residing in nursing homes cannot care for themselves, they require assistance with oral care. Associations between xerostomia and bronchopneumonia, plaque and respiratory pathogens, and periodontal disease and cardiovascular disease are of concern, particularly for the chronically ill and fragile older adult.69 As functional capacity declines, the individual is at greater risk for caries, periodontal disease, and tooth loss. These conditions further lead to pain, infection, access to care and financing issues, and systemic complications. In addition, most older adults in long-term care facilities take up to 10 or more medications daily.56 Drug-induced oral side effects are very common.

Unfortunately, the nursing home staff typically seeks dental intervention when tooth loss or ill-fitting dentures interfere with a resident’s eating or infection causes the resident to complain of pain or discomfort. Missing, decayed, or fractured teeth require the consumption of soft foods that are usually highly cariogenic, potentiating the risk for caries. In addition, weight, facial appearance, communication, and socialization also are adversely affected by poor oral conditions. Residents and even staff members often misplace prosthetic oral appliances and this poses an additional oral health concern. Denture identification markings are advised for all residents who wear prostheses73 (Figure11).


The Role of Nursing Personnel in Oral Care

According to in the 2000 Surgeon General’s report on oral health in America, nursing staff involvement in daily oral care for the hospitalized or institutionalized older adult is critical. Mouth care is frequently viewed as an unpleasant, tedious, time consuming task and is therefore relegated to nurse assistants. Nursing personnel in general receive very little oral health education during their educational preparation. Therefore, barriers to the provision of oral care by nursing staff include a lack of knowledge about oral disease and management, a perceived lack of time to provide oral care, and the perception that oral health care is less of a priority in the total scheme of duties they are responsible for rendering.44

Research has shown that educational in-service programs delivered by a dentist or dental hygienist to nursing staff of long-term care facilities result in minimal benefits to the resident population. However, when staff received training and support from other members of their staff, rather than oral health care practitioners, improvements in care were reported.69 In defense of the staff, turnover rates are extremely high in long-term care facilities and staff-to-patient ratios are often unrealistically high. Therefore, rewards must be in place to change behavior and make oral care an integral part of all residents’ treatment plan for nursing personnel.


Elder Abuse

It is estimated that more than one million older Americans are victims of mistreatment each year. Dependent older adults are often at risk for mistreatment by family members or staff at the institutions where they reside. Oral health care professionals are in a logical position to observe signs and symptoms of elder abuse, particularly when the head and neck are involved. Head and neck injuries are the most common form of physical abuse involving older adults. Bruises and welts occur most frequently, followed by broken prostheses, abrasions or lacerations, and fractured or avulsed teeth. The most common forms of physical neglect consist of failure to provide personal hygiene and medical and oral health care. Intervention by oral health educators should include identification of the mistreatment, detailed documentation in the patient record, and referral to social support services.74,75


Summary

There is no question that the role of dental hygienists in managing the oral health needs of the older adult is a significant one. Many factors must be considered prior to and during the provision of oral health care to enhance the access, comfort, and safety of older adults. Factors include thorough assessment of the patient’s medical history (medical conditions, drug therapy, vital signs, and cognitive and functional abilities) and social history (living arrangements, significant others/ caregivers, transportation availability to access oral health care, and financial status). Dental hygienists must keep in mind that each older adult should be treated as an individual, just as any patient would be treated. Making decisions for older adult patients instead of with them can compromise rapport between patients and dental hygienists and can affect adversely the treatment outcome. In cases of cognitive impairment, such as dementia, a significant other or caregiver may facilitate planning and implementing appropriate treatment.


Supplemental Activities

  1. Assess the oral health services provided by nursing homes in the area where you live.
  2. Conduct an oral cancer screening at a local senior center.
  3. Try a few simple exercises to empathize with older adults by simulating some of the physical limitations they may experience while trying to see, hear, or ambulate:
  4. Spread a lubricant such as vegetable oil over the lenses of a pair of nonprescription glasses
    Put cotton in your ears and try to listen to someone giving you directions
  • Put a pair of gloves on and insert the middle and forefingers into one opening. Try turning the pages of a book or counting out pocket change.
  • Place popcorn kernels in the bottom of your shoes and walk up and down a flight of stairs.
  • With an assistant, sit in a chair that can spin and have the other person spin you around while closing your eyes. Try to stand immediately when the chair stops.
  • View Web sites for additional information on oral care for older adults.
  • www.census.gov
    www.health.gov/healthypeople
    www.surgeongeneral.gov/library/oralhealth
    www.nidcr.nih.gov
    www.nohic.nidcr.nih.gov
    www.nia.nih.gov/health/pubs/clinicians-handbook
    www.merck.com/pubs/mm_geriatrics/tables/104t2.htm
    www.alz.org
    www.aoa.gov
    www.seniorsource.com
    www.medscape.com
    www.outreachdentistry.com
    www.medinfosource.com
    www.ncoa.org
    www.go60.com
    www.americangeriatrics.org
    www.asaging.org
    www.cdc.gov
    www.dentalcare.com
    www.adha.org
    www.ada.org