The elderly are rich in diversity, poor in oral care

Jan. 1, 1999
Who will be prepared to meet the oral-care needs of this unique age group? Will dental hygienists walk into the new millennium ready and willing to face the formidable task of meeting the complex needs of the expanding older adult population?

Who will be prepared to meet the oral-care needs of this unique age group? Will dental hygienists walk into the new millennium ready and willing to face the formidable task of meeting the complex needs of the expanding older adult population?

Cathleen Terhune Alty, RDH

More of our nation`s population is reaching old age (85 years and up), leading to the phenomenon of the "graying of America." Many of these octogenarians are blowing out birthday candles with some of their own teeth in their mouths. The statistics are compelling. Thirty percent of 65- to 74-year olds were edentulous in 1986. It is estimated that only 10 percent of 65-to 74-year olds will be edentulous in 2024.

"The fastest growing age group is 85 and over," says Dr. Ronald L. Ettinger with the department of prosthodontics and The Dows Institute for Dental Research, University of Iowa. "Likewise, an increasing percentage of dentate adults will have more teeth which are at risk for caries and periodontal disease."

The risk appears to be great. Studies reveal greater incidence of caries in the population over age 65 than in the under-14 population. Seventy-five percent of older adults take at least one prescription medication, which potentially decreases saliva production.

Who will be prepared to meet the oral-care needs of this unique age group? Will dental hygienists walk into the new millennium ready and willing to face the formidable task of meeting the complex needs of the expanding older adult population?

"This population is more diverse than any other single group," says Dr. Lea Erickson, chief of dental services at the Department of Veterans Affairs Medical Center in Salt Lake City. "Unfortunately, many people lump them into a single group, and some simply see them as old, sick, and forgetful."

The diversity has led geriatric experts to classify the older adult population by age groups: the young-old (ages 65-74) the middle-old (ages 75-84), and the old-old (ages 85 years and over). This classification system reflects physical changes that are related to the ravages of time, including changes in the oral conditions and in the overall health of the person.

Many older adults are healthy and completely functional. But, as a general rule, the older the patient the greater the loss of function, motivation, dexterity, and cognitive ability. Greater bone loss, tooth loss, and caries experience will be observed as a function of time. Add in the effects of systemic health problems and prescription medications that alter salivary flow, and patient care suddenly gets very complicated.

One challenge is maintaining the teeth the older patient has retained. Dr. Kenneth Shay, chief of dental services at the Ann Arbor, Mich., VA Medical Center, focuses on caries as a major problem in older adults. He points out that, in general, the geriatric dentition is at-risk for destruction due to root caries. Absent or altered saliva flow due to chronic disease (and particularly as the side effect of prescription drugs) is a real issue, according to Dr. Shay.

"For example," he explains, "there is no solid data that people with dry mouths have worse periodontal disease. Even when you factor in more plaque, it`s not out of proportion. But a patient with a dry mouth has dental caries way out of proportion to the amount of plaque."

Plaque is a problem due to many factors. Older adults, Dr. Shay says, often have reduced visual acuity at the bathroom mirror while brushing, affecting the thoroughness of brushing because "they simply can`t see what they`re doing." In addition, manual dexterity is reduced as a person ages, making it more difficult to grip a small toothbrush handle. The reduced mobility includes prime areas that are attacked by arthritis, such as the arms, elbows, and shoulder joints. "Electric toothbrushes," Dr. Shay points out, "are helpful because all the patient has to do is hold it against the tooth surface."

Diet also influences any plaque problems, especially when considering diminished salivary flow. "Small, frequent dosages of sugar can be devastating to the dentition," says Dr. Shay. "We often see people who drink frequent sips of cola or coffee or suck on hard candies such as lemon drops to relieve a dry mouth."

Missing teeth also compound the plaque problem. "When teeth are not replaced," says Dr. Shay, "the spaces become food traps. When the teeth drift and tip, it makes it harder to thoroughly remove plaque. When missing teeth are replaced with something like a fixed bridge, many patients are not educated by their dentist to clean under it."

Partials add to the plaque- and food-retention areas, as well as place additional forces on abutment teeth. Attachment loss, he said, is a "double whammy. There is literally more tooth to keep clean and more root surface exposed to plaque which leads to root caries." Dr. Shay believes that, if the plaque problems are resolved, many periodontal problems are resolved as well.

Dr. Erickson adds, "Periodontal disease is a significant concern as more older adults retain their teeth. This disease

process does not appear to be the result of the aging process but, instead, to be the consequence of the additive influence of lesions over time."

She says that plaque control is critical for control of periodontal disease and caries. Dr. Erickson perceives an increased need for preventive services for older adults. "The stereotype is that the older patient doesn`t seek dental services," she says. "But the literature suggests that this may not be true for the older adults with natural teeth and will most certainly be less true with each cohort who passes his or her 65th birthday."

Another challenge to serving this population is educating dental hygienists to safely and effectively treat medically compromised, older adult patients.

"I believe that dental hygienists have a major role in the care of aging adults, particularly in hospitals and long-term care facilities," said Dr. Ettinger. "But to do that, there is a need for more than just the skills they have now, particularly in the areas of oral medicine and pharmacology. You need to learn to deal with patients with drug-related problems. You need to really understand the drugs they are taking, what the medications do for the patient, and how they affect dental hygiene treatment. You need to know how to read a medical chart, how to look up drugs and read scientific literature, and understand how to identify a good study."

Dr. Ettinger points out that medicines change very quickly. As an example, he cites how phantoin sodium (Dilantin) was "once upon a time the drug" that caused gingival overgrowth. Now many medications result in this side effect, including calcium channel blockers used to treat hypertension or the immunosupressants used after organ transplants.

"Another example is a patient taking corticosteroids who requires a deep scaling," Dr. Ettinger says. "How much hydrocortisone is the patient taking and for how long? You may need to remind the dentist that the patient may need supplemental cortisone for that day from his physician. You have to learn to work with the dentist and physician on these cases."

It will be interesting to see how America handles the aging of its population and where dentistry will fit in. Will care be cost effective? What training will be necessary, and who will provide it? Will states without indirect supervision change so hygienists will be able to work in more nontraditional locations? Hygienists can play a major role in how care is delivered. Are we ready for the challenge?

Cathleen Terhune Alty, RDH, a frequent contributor to RDH, is based in Rochester Hills, Mich.


1.) Assessment - "Determine the needs and capabilities of the patient. Don`t just look at the dental aspects, but also at the physical and mental health considerations; their routines; and social, financial, and transportation requirements. If they are given a prescription for fluoride rinse and are already paying $300 for other prescriptions and drugs, many don`t have the money for more medicine."

2.) Communication - Take the time to really converse with the patient. Engage the patient or caregiver as a partner in the oral health process. It should be a collaborative process. Instead of saying, "Do this and this, then do this," ask which procedure they could incorporate into their routine. For example, if flossing is not an option, ask, "What other ways could we achieve this same effect?"

3.) Begin immediately - "Get the habit started early. Get the patient or caregiver in a routine as quickly as you can. Especially with a patient with Alzheimer`s disease, you engage the patient as soon as possible because his or her health will only go downhill."

4.) Capitalize on the fitness interest - "There are so many senior programs like nutrition and exercise classes; we can build on this interest and capitalize on this consumer mentality by giving them ways that they can keep the teeth they have and prevent additional problems. These older patients see themselves as survivors when they still have their natural teeth, and they are proud of it."

Dr. Erickson:

1.) "Update the patient`s medical history. Tremendous changes may occur in six months. If the patient is taking many medications, it may be more effective to ask the patient to bring them in so you can record them. If you don`t know what the medications are for, look them up in a drug reference book which gives specific dental implications that may be problematic with dental treatment."

2.) Change recall interval whenever necessary. "Changes in physical status often mean changes in dental status as well. Every preventive technology and technique available should be applied, including fluoride for adults with active caries. Both recall interval and preventive aids should be individually adapted to the patient`s needs and ability after a thorough assessment is completed."

3.) Train caregivers. "If the patient has no ability to maintain his/her own oral health, the caregiver needs to be trained. A combination of brushing and chemistry is often indicated. Strategies may include a brushed-on chlorhexidine or a product like Prevident Plus 5000 used in lieu of toothpaste. Automated toothbrushes are helpful for some patients, especially those with a larger handle. Toothbrushes like the Collis Curve or the Superbrush brush occlusal, lingual, and facial surfaces at the same time. A brush that attaches to a vacuum is useful for a patient who has suffered a stroke and has difficulty swallowing."

4.) Dental facility. "The dental office should be well-lighted, but older adults have difficulty seeing when there is excessive glare. Even the health history form should have good contrast - no blue printing on blue paper, for example, and the font should be easily read. Hearing loss is common among older patients, so as much background noise as possible should be eliminated. Facing the patient when speaking and removing masks will enhance communication. Floor surfaces should be level with no obstacles. A cardiac patient may be unable to lie with the chair all the way back. Arthritic joints sometimes take a bit longer to move, so the dental chair should not be moved back or forward too quickly. Patients with arthritis may prefer appointments later in the day to allow some time to get their joints moving. When it is time for the patient to get up from the dental chair, the chair should not be completely lowered. Getting up is easier for an older person when the chair is slightly elevated."

Root caries risk assessment

Dr. Kenneth Shay of the VA Medical Center in Ann Arbor, Mich., suggests caries-prevention regimens for older patients by classifying them into three progressive caries risk categories: Low risk, moderate risk, and high risk. The risks are based on the caries activities during the last three years. The best predictor of root caries appears to be the previous root caries experience of the person. Other risk factors include: quantity and composition of plaque, diet (fermentable carbohydrates), coronal caries experience, saliva, number of exposed roots, active periodontal therapy, smoking, systemic illness, number of periodontal pockets greater than 3 mm in depth, and fewer than nine remaining teeth.

The categories and suggested regimens are:

Low risk - Suggest patient use a fluoride dentifrice (Dr. Shay reports that one-third of people over age 75 do not use a fluoride toothpaste). Make sure the patient is aware that fluoride dentifrices really are very effective in preventing root caries. He is not convinced fluoride mouthrinses make any difference, but if a patient uses a mouthwash anyway, go ahead and suggest a fluoride-containing product.

Moderate risk - The above regimen for low risk, plus more frequent recall interval plus in-office fluoride treatment (APF fluoride or 12,000 ppm sodium fluoride).

High risk - The moderate risk regimen plus a home-use fluoride (neutral sodium fluoride) once per day. A custom fluoride tray (modified bleaching tray) may be helpful and because of drooling, suggest that the patient use the trays while in the shower.

Dr. Shay is also an advocate of Xylitol-sweetened chewing gum. Biotene gum is available over-the-counter and appears to reduce plaque by reducing strep mutans bacteria, reducing both caries and gingivitis. The company that manufactures the gum (Laclede in Gardena, Calif.) also makes other products for dry mouth that appear promising, like an alcohol-free mouthwash and oral lubricant.