Oral health in older adults

Despite global efforts to promote oral health, this aspect of health care remains a major challenge among disadvantaged and marginalised populations. Ageing brings its own challenges that impacts daily life. According to World Health Organization (WHO) (2018), the world population of those aged over 60 years is expected to double from 12% to 22% by 2050. This dramatic increase will no doubt put a huge strain on the healthcare system as well as quality of life. With ageing, mental and physical capacity gradually decline, leaving individuals requiring assistance to carry out their daily tasks. Although there are some individuals in their 70s or 80s with good health and functional abilities, there are others with health conditions who need regular support with daily living.

The most common oral conditions among older people are dental caries (decay), periodontal disease (gum disease), dry mouth and soft-tissue lesions, and numerous risk factors contribute to the development and progression of these diseases. The purpose of this article is to provide an overview of general health problems impacting the oral health of the older population. In particular, it discusses some of the common diseases, medications and treatments that significantly affect the oral health of these individuals. It is hoped that this article will raise awareness and enhance the knowledge of community nurses in providing care or advice related to dental health.

Dental caries

Dental caries is a biofilm-mediated, diet-modulated, multifactorial disease caused by bacteria (Machiulskiene et al, 2020), where acid produced as a byproduct of the bacterial metabolism of sugars in the mouth destroys the hard tissues of the teeth. Factors influencing the rate and progression of caries are sugar intake, the frequency of intake, acidity of the mouth, saliva and fluoride (Moynihan, 2016). Further, several conditions and medications also affect the rate of caries occurrence and progression. If caries is left untreated, it can result in severe pain, swelling and, eventually, tooth loss. Dental caries is a major problem among the older population. A study by Silva et al (2014) found that dental caries are significantly common in nursing homes and twice as common in patients with dementia than in those without it. With deteriorating cognitive ability, persons tend to forget daily oral care such as toothbrushing and flossing. Further, most of these individuals are unable to cook for themselves, resorting to ready-made meals that are high in sugar.

Losing one or two teeth will not cause much trouble, but becoming edentulous (loss of all natural teeth) can have a significant effect on other aspects of health. This is particularly upsetting, not only from a functional viewpoint but also from the social aspect. It can be an emotional burden for the individual, affecting their confidence and potentially inducing anxiety and depression. From a functional aspect, particularly in the older population, eating and chewing are compromised, and affected individuals can become malnourished.

Prevention of dental caries is difficult due to its multifactorial nature, but good oral hygiene, reduced sugar intake and use of toothpaste with a sufficient concentration of fluoride (1350–1500 ppm for adults) are just some of the critical steps in controlling the disease (Fejerskov, 1997).

Gingivitis/periodontitis (gum disease)

Gingivitis is referred to as the inflammation of the gums, while periodontitis is gum inflammation together with the loss of tooth-supporting tissues and bone (Shaw et al, 2016). Bone provides structural support for teeth. Without good bony support, teeth drift apart and eventually become loose. Periodontitis is a chronic inflammatory disease induced by bacteria, leading to a decrease in bony support. Approximately 20–50% of the world population is affected by periodontitis (Nazir, 2017). The main risk factors are poor oral hygiene, smoking, hormonal changes in girls and women, diabetes, medications, stress and ageing (Wu et al, 2016).

There is strong evidence highlighting the link between periodontal disease and other systemic diseases, such as cardiovascular disease and diabetes. The risk of cardiovascular disease is increased by 19% for those with periodontal disease, and this risk increases to 44% among those over the age of 65 years. People with type 2 diabetes and severe periodontal disease have a three times higher risk of mortality than those without these conditions (Nazir, 2017).

Periodontal disease can be prevented by exercising good oral hygiene, by brushing twice a day, flossing and use of some mouthwashes. Regular dental checkups are also recommended, with professional interventions such as scaling and polishing. In the case of those with impaired functional abilities, supervised toothbrushing is advised (Ferriera et al, 2016).

Dentures

Dentures or implants are used to replace missing natural teeth. Removable dentures are worn by 20% of the UK population (Hannah et al, 2017). The advantages of removable dentures are that they are cheaper and less invasive. Adapting to dentures can be a challenge for some, especially those with systemic diseases affecting muscle control. Good facial muscle control, coordination and patient tolerance is required to retain the dentures in the mouth, otherwise they will rock and fall out of the mouth, causing embarrassment for the wearer and difficulty eating and speaking.

Denture hygiene is an important issue to address. Lack of denture hygiene can lead to many problems, a common one being denture stomatitis, which is inflammation of the gum tissues that are covered by the dentures. In addition, plaque buildup on the dentures can lead to aspiration pneumonia, a condition that older patients are at a high risk of contracting, especially if they wear their dentures at night (Hannah et al, 2017). The dental team providing the dentures must provide thorough denture hygiene advice, and regular dental checkups are recommended.

Chronic dry mouth (xerostomia)

Dry mouth, known as xerostomia, can occur as a result of certain medical conditions, for example, Sjögren's syndrome, an immune condition leading to dry eyes and mouth. However, one of the main causes of reduced salivary flow in older adults is the high frequency of polypharmacy, in particular, antidepressants, diuretics and antihypertensives (Altamimi, 2014). Previous radiotherapy in the head and neck region can also affect saliva production, causing radiation-induced xerostomia. Other causes include:

• Side effects of medications
• Ageing
• Surgical removal of salivary glands
• Medical conditions, such as HIV, Alzheimer's disease, hypertension, rheumatoid arthritis and diabetes mellitus
• Dehydration
• Lifestyle.

The composition and functional abilities of saliva contribute significantly to the maintenance of oral health (Pinna et al, 2015). Saliva has various functions, including:

• Lubrication-moisturises the mouth and produces better and clear speech
• Chewing and swallowing-helps with chewing food without causing damage to the soft tissues of the mouth.
• Solubilisation of food-helps with taste of the food after the food is solubilised by saliva
• Oral hygiene-flushes the mouth and helps remove food debris
• Antibacterial effect-fights against pathogens that cause dental caries.

In denture-wearing patients, lack of or reduced saliva results in sores, as dentures damage the soft tissues of the mouth. Lack of taste and difficulty in swallowing and chewing food and speaking are common complaints among older adults with xerostomia, which contribute to reduced nutritional intake (Pinna et al, 2015). Although it is difficult to treat the underlying cause, it is important that health professionals attempt to alleviate the symptoms by offering advice as follows (Visvanathan et al, 2010):

• Affected individuals should sip water from time to time
• They should use an alcohol-free mouthwash, saliva-replacement gels or chew sugar-free chewing gum
• They should avoid coffee and alcohol.

Oral lesions

Like the rest of the body, the oral cavity undergoes significant changes as people age. Any abnormal appearance of the soft tissues of the mouth is referred to as a lesion. Ulcerations, pigmentations and red-white lesions are some that occur in the oral cavity (Mortazavi et al, 2019). Since these can be benign or malignant, they all warrant referral to specialist services for further investigation.

According to National Institute for Health and Care Excellence (NICE) guidelines (NICE, 2017), the following changes in the mouth require urgent referral:

• Any unexplained ulceration in the mouth lasting for more than 3 weeks
• Persistent lump in the neck
• A lump on the lip or oral cavity
• Red and white patches.

Prolonged use of certain medications, smoking, chewing betel nut and excess alcohol consumption play an integral role in development of oral lesions (Rohini et al, 2020). Smoking plays a crucial part in aetiology of oral cancer, shown in 81–87% of oral cancers in men (Naveed, 2017).

Keeping medication in the mouth for prolonged periods of time or the use of other topical drugs can lead to chemical burns of the soft tissues (Mortazavi, 2019). It can be uncomfortable and the cause of unnecessary worry. Older people with progressive cognitive impairment are sometimes known to keep medication in their mouth. In addition, ulcers from repeated trauma to the soft tissues can occur as a result of a sharp tooth or eating hard foods and need to be investigated.

Bacterial and viral infections are common in the mouth. The oral cavity contains over 700 bacterial species (Grinde et al, 2010). Poor denture hygiene and leaving them overnight are common or oral infection. The herpes virus is also well-documented to cause ulcers and, possibly, oral cancer (Grinde et al, 2010). Any growth, lesions, ulcers or other abnormalities noticed in the oral cavity must be referred to the specialist services for further investigation to exclude the possibility of malignancy.

Common diseases and conditions impacting oral health

There are a number of systemic diseases effecting oral health in different ways. This article focuses on the three main progressive diseases, namely, dementia, Parkinson's disease and osteoarthritis.

Dementia

People with dementia tend to be over the age of 65 years, although the prevalence in younger people is increasing. Dementia is an umbrella term for progressive neurological disorders characterised by mental deterioration and memory loss, leading to disability and death (Alzheimer's Society, 2014). There are more than 850 000 people living with dementia today, and the numbers are expected to rise. Behavioural changes are common in patients with cognitive decline. It is shown that toothbrushing becoming less frequent is an early indication of cognitive impairment (Naorungroj et al, 2013). Taking consent and providing access to oral healthcare and dental treatment are challenges faced by dental teams. It is important to provide carers of dementia patients with prevention advice to ease the burden on the healthcare system as well as to improve patients' quality of life.

Parkinson's disease

Parkinson's disease is a progressive neurodegenerative disorder characterised by tremors, continuous uncontrolled movement, rigidity and behavioural dysfunction (Alomari et al, 2017). There are many dental implications of this disease, from both the patient's and the dentist's viewpoint. Patients are at increased risk of developing dental disease due to dry mouth as a result of the large amount of medication. This, in turn, leads to dental decay, gum disease, chewing difficulties and denture problems. In addition to motor impairment, cognitive changes can lead to neglected oral care, which subsequently leads to oral health deterioration, pain and discomfort. From a dentist's perspective, treating patients with Parkinson's disease can be difficult, and tremors can get worse along with dental anxiety. Generally, short, early morning appointments are recommended, and any medication should be taken at a time to ensure a peak response (Al-Omari, 2014). Patients with Parkinson's disease must visit the dentist regularly for preventive care. Some patients may benefit from treatment under sedation or general anaesthesia.

Osteoarthritis

Osteoarthritis is a degenerative joint disease resulting in gradual deterioration of the joint cartilage, with proliferation and remodelling of the bone. The symptoms include pain and decline in motor function (Kelsey et al, 2008). The hands, knees, spine and hips are frequently affected. Oral hygiene is affected by impaired motor ability, resulting in increased dental decay and gum disease (Pokrajac-Zirojevic et al, 2002). Certain medications used to treat osteoarthritis including corticosteroids and non-steroidal anti-inflammatory drugs can suppress the immune system, and there is a risk of delayed wound healing, infections and bleeding. The temporomandibular (jaw) joints are the most frequently used joints in the body (Ringold et al, 2009), and those with arthritis can experience jaw pain when chewing and speaking. Prolonged dental appointments will exacerbate pain and discomfort, so all dental appointments must remain short and patients can take analgesics before the appointment according to their dentist's advice. With debilitating pain, attending dental appointments and moving around can become difficult for individuals who are dependent, and in some instances, they may require specialised transport (Pokrajac-Zirojevic et al, 2002). Dental appointments should be booked with sufficient time to accommodate reduced mobility (Kelsey et al, 2008).

Medication affecting oral health

There are multiple drugs that affect oral health. Bisphosphonates (BPs), which are drugs commonly used for multitude of health conditions, work against osteoclast-mediated bone loss caused by osteoporosis, Paget disease, multiple myeloma, hypercalcaemia, malignancies metastatic to the bone and inheritable skeletal disorders (Drake et al, 2009). Although BPs can offer substantial benefits, their oral health implication are well-documented in relation to osteonecrosis of the jaw. BP-related osteonecrosis of the jaw (BRONJ) is caused by trauma to the jaw bone, such as tooth extraction, in patients who have limited capacity for bone healing due to the effects of BP therapy. The diagnostic hallmark of BRONJ is if there is exposed bone after 8 weeks of surgery/tooth extraction and the patient has no history of radiotherapy in the head and neck region (Khosla et al, 2007). Incidences of BRONJ are related to the dose and duration of BP therapy. Patients on oral BP therapy have a lower chance of developing BRONJ than those on intravenous therapy (Hess et al, 2008). Risks factors for developing BRONJ include:

• Surgical procedures such as tooth extractions or any periodontal treatment
• Comorbidities such as diabetes mellitus, cancer, previous treatment with chemotherapy and renal dialysis
• Use of dentures
• Infection
• Genetic predisposition.

The signs and symptoms of BRONJ are pain, soft-tissue infection with ulceration and suppuration; formation of intra-extra-oral sinus tracts and fistulas; numbness; pathological fracture; and chronic sinusitis.

Before initiation of BP therapy, patients are encouraged to undergo dental checkup and treatment to prevent any dental complications. Treatment for BRONJ is effective pain control, antibiotic treatment with debridement and regular use of 0.12% chlorhexidine antiseptic mouth wash (Gupta et al, 2020).

Anticoagulants

The use of anticoagulants, particularly warfarin, in older patients is common. Warfarin is a vitamin K antagonist that is used to thin the blood. The older population is at high risk of atrial fibrillation, which results in thrombus formation in the left atria and subsequent embolisation to the brain, causing stroke or arterial thromboembolism. Warfarin prevents thromboembolic complications (Amin et al, 2016). In dentistry, any invasive procedure such as periodontal treatment or tooth extraction carries a risk of postoperative bleeding that, in some cases, warrants hospitalisation. Prior to every invasive dental procedure, patients on warfarin must have their international normalised ratio (INR) checked ideally no more than 24 hours before the operation (Scottish Dental Clinical Effectiveness Programme (SDCEP), 2015). Patients with an INR below 4 can be safely treated. The treatment should be carried out without interrupting the medication. The dentist should take local measures to pack the extraction socket with haemostatic agents and sutures.

If the INR exceeds 4, treatment should be delayed and the dentist must liaise with the patient's GP. Warfarin also interacts with a number of antibiotics, and metronidazole, erythromycin and other macrolides should be avoided (SDCEP, 2016).

Novel oral anticoagulants

The new class of anticoagulants commonly prescribed for prevention of stroke for people with non-valvular atrial fibrillation are apixaban, dabigatran and rivaroxaban (British Heart Foundation, 2020). There is increased bleeding risk in these patients, and dentists must be made aware if they are on any of these medications. The SDCEP (2015) guidelines recommend that patients on these medications need to be treated early in the morning; those on apixaban and dabigatran can miss their medication on the morning of their invasive dental procedure and rivaroxaban can be delayed. Each patient should be treated individually and according to their medical history. All these patients undergoing invasive dental procedures should receive packing and suturing of the surgical site.

Oral health advice

‘Delivering better oral health: an evidence-based toolkit for prevention’ developed by Public Health England and the Department of Health and Social Care in 2007 focuses on prevention of oral diseases. This document is easily accessible, presented clearly and enables health professionals to better understand measures to improve oral health. Table 1 summarises basic advice available for caries and periodontal disease prevention, as well as denture hygiene advice, which is important for denture-wearing persons, carers or community nurses.

Conclusion

It is no secret that the characteristics of the world population are changing, and the increase in the ageing population will pose further challenges in the years ahead. Conditions such as Parkinson's disease, arthritis and dementia impact the oral health of an individual, causing both physical and emotional symptoms. In addition, treatments for cancers and other related medications further compromise the dental status of a person. As a result, practice of good oral hygiene and regular visits to the dentists are essential for preventive care. Although it is the responsibility of dental health professionals to provide education about the maintenance of good oral health, community nurses are at the forefront of caring for the older population. This makes their role more important than ever, as these individuals depend on their community nurses for guidance and assistance. Thus, it is vital that community nurses continue building on their knowledge, awareness and understanding of oral health and the associated implications to ensure good quality of life among their patients.

KEY POINTS

• Multiple comorbidities and lifestyle factors put the older population at high risk of developing oral diseases
• Poor oral health places older adults at risk of other health risks, including malnutrition and cardiac disease
• Common conditions that impact the oral health of older adults include Parkinson's disease, osteoarthritis and dementia
• Community nurses are well-placed to educate and advise older adults on maintaining good oral health

CPD REFLECTIVE QUESTIONS

• Why is poor oral health prevalent in the older population?
• What are the common risk factors for development of oral lesions?
• Name three progressive diseases that have a significant impact on oral health
• List common causes of dry mouth