Prevalence and impact

Dental caries (decay) is the progressive destruction of tooth structure caused by acids produced by sugars and bacteria in the oral cavity (Figure 53-1). If untreated, dental caries can progress into the pulp of the tooth, causing pain and a dental abscess, which may lead to bacteremia, facial/pharyngeal infection, septicemia, and in rare cases cavernous sinus thrombosis.

Because an increasing number of adults are retaining their teeth throughout their lifetime, dental decay is increasing in the elderly. Nearly one third of older adults have dental caries, averaging one new carious surface per person per year. Decay in elders is more likely to go untreated; elderly have four times the mean number of untreated carious surfaces compared to U.S. schoolchildren.¹⁴

Approximately 86% of adults older than age 65 experience recession (gums pull away from the teeth). This is not a normal part of aging but instead is caused by periodontal disease or trauma from overzealous toothbrushing. Tooth roots are exposed by recession, and cementum, which covers the roots, is more susceptible to decay than enamel. Elders are therefore more prone to root caries than their younger counterparts.¹⁵ In fact, root caries is the most common type of decay in elders. A study of community-dwelling elders found 52% had a history of root caries and 22% had active untreated root caries.¹⁶ This type of decay progresses rapidly and will amputate the tooth at the gum line if untreated.

Risk factors and pathophysiology

A diet high in carbohydrates is a major risk factor for dental decay. Declines in cognitive and physical function impair the ability to brush and floss one’s teeth and increase the risk of decay. Institutionalized elders may experience 3 times the prevalence of decayed teeth compared to community living older adults.¹⁷ Dry mouth, often induced by medications, is another important risk factor for caries.

Differential diagnosis and assessment

Decayed teeth in older adults are generally less symptomatic than in younger adults. Active decay has a yellowish brown color. Early root decay appears broad and shallow. Decay on the crowns of teeth is usually found around preexisting fillings or crowns (see Figure 53-1). Dental radiographs and transillumination are helpful in diagnosis.

Management

Timely treatment of decay is very important to reduce destruction of tooth structure and decrease the risk of the decay progressing into the tooth pulp and causing an abscess. Dental amalgam (silver filling material) and composite (white filling material) are the two most common dental materials used to restore a tooth after decay has been removed. When the affected areas are expansive, pins or other retentive approaches are used to enhance longevity of the restoration. When restoring more than half of the crown of the tooth, full coverage of the tooth using gold or porcelain (often called a crown or cap) may be the best treatment. Full coverage of a tooth involves more treatment time and significantly more expense. It is much easier on the patient and more cost-effective to address decay at the earliest possible time.

Prevalence and impact

Periodontal disease (periodontitis or gum disease) is progressive disease that begins as inflammation of the gingiva (gingivitis). If left untreated, gingivitis progresses to a more severe inflammatory disease that destroys the alveolar bone supporting the teeth. In severe periodontal disease, the teeth become mobile and are often lost. Periodontal disease is the primary cause of tooth loss in adults.

The prevalence of periodontal disease has decreased since the 1970s. However, more than 17% of adults older than age 65 have periodontal disease compared to 8.52% of adults age 20 to 64. This prevalence is higher in adults with low income, less education, and black or Hispanic ethnicities.¹⁸

Risk factors and pathophysiology

Periodontal disease is caused by bacteria in dental plaque. Failure to effectively remove plaque by proper oral hygiene and professional cleanings results in an accumulation of plaque and calculus (mineralized plaque) that induces inflammation and infection of the gingiva and alveolar bone (Figure 53-2). Other risk factors include smoking, diabetes, osteoporosis, osteopenia, genetics, and hyposalivation.

Differential diagnosis and assessment

Early periodontal disease is characterized by redness, bleeding, and edematous gingival tissues. As the disease progresses, bone surrounding the teeth is destroyed (see Figure 53-2). As a result, teeth become mobile. Diagnosis of periodontal disease involves measuring the depth of the periodontal pockets with a probe and radiographic examination to determine if bone loss has occurred. The entire oral cavity, including teeth, needs to be examined to determine the extent of periodontal disease.

Management

The most important approach to management of periodontal disease is removal of plaque and calculus by effective brushing, flossing, and tooth scaling by dental professionals. More frequent dental visits for removal of plaque and calculus may be warranted. Other management strategies include use of pharmacotherapeutics (e.g., chlorhexidine gluconate rinse and Listerine), improved management of systemic diseases (e.g., diabetes and osteoporosis), smoking cessation, and locally applied and systemic antibiotics. Surgery is sometimes necessary to manage extensive bone loss.

Prevalence and impact

Xerostomia (the patient’s subjective complaint of mouth dryness) and hyposalivation (the objective reduction in salivary secretion) are correlated and prevalent problems in older adults. Approximately 30% of adults 65 and older suffer from xerostomia.¹⁹ Saliva is essential to maintain oral and general health. Dry mouth reduces comfort and quality of life. Constant mouth dryness may reduce compliance with prescription medications; patients may alter dosage or stop the drug altogether. It may also restrict dietary choices and compromise nutrition by making chewing and swallowing uncomfortable, altering taste, and diminishing food enjoyment. Lack of adequate salivation is associated with chronic esophagitis and gastroesophageal reflux disease (GERD).²⁰ Dry mouth increases the frequency and severity of dental caries. There is often rampant, rapidly progressive decay that is difficult to manage and more substantial periodontal disease in individuals suffering from mouth dryness. Also the patient’s ability to tolerate a denture is compromised because of lack of lubrication of oral tissues.

Risk factors and pathophysiology

Salivary flow does not decline with age; medical conditions and their treatment, rather than age, are associated with mouth dryness. The most common cause of hyposalivation is medication use. Many drugs used to manage issues in older adults contribute to oral dryness; these include sedatives, antipsychotics, antianginal agents, antidepressants, antihistamines, antihypertensives, antiparkinson agents, diuretics, and anticholinergics. Sjogren’s syndrome is the most common salivary gland disorder in the elderly leading to xerostomia. Reduced saliva may also be a result of patient dehydration or salivary duct obstructions such as sialoliths, infections, tumors, head and neck radiation, diabetes, and Alzheimer’s disease.²¹

Differential diagnosis and assessment

Clinical signs of mouth dryness include dry, ulcerated, reddened, or furrowed lips and intraoral mucosa; generalized desiccated tissues with a lack of saliva pooling in the floor of the mouth; a fissured or inflamed tongue, and the presence of halitosis. Assessment can also be aided by palpating or “milking” the parotid gland. An unexpected rise in dental caries and the presence of fungal infections may be sequelae of a dry mouth. The patient may also complain of xerostomia, burning mouth, sore lips and tongue, as well as having difficulty with swallowing, taste, speaking, and denture use.

Management

Preventive care is first in managing dry mouth; fluoride therapy, an antimicrobial mouth rinse, and reduction of refined carbohydrate consumption can mitigate the elevated risk of dental caries and periodontal disease. Patients should be encouraged to visit their dental provider often to screen for dental caries. If a patient’s medication is known to inhibit salivation, an alternative drug in the same class should be considered. Some have recommended modifying medication schedules so that the peak hyposalivary effects occur during mealtimes when there is a natural stimulus for salivation.

In many cases topical treatment using a saliva substitute may be helpful. Over-the-counter saliva substitutes include Oral Balance gel (Laclede products) and Mouthkote (Unimed). Salivary stimulants such as sugarless Biotene Xylitol gum (Laclede Products) and sugarless candy may also be helpful. Systemic salivary stimulants (pilocarpine) may be used, especially in patients with Sjogren’s syndrome, but should be avoided in those with glaucoma or pulmonary disease. Patients should be encouraged to drink plenty of water and avoid alcohol and caffeine.²²

Prevalence and impact

In the 1950s half of all Americans older than age 65 had lost all of their natural teeth.²³ Today the edentulism rate of older adults has decreased to 18%.²⁴ The downward trend in edentulism is largely the result of fluoridation of community water, increased education about prevention of oral disease, and increased access to dental care.

Adverse outcomes of edentulism include difficulty chewing and speaking, poor esthetics, and lowered self-esteem. A recent study found 45% of denture wearers have oral lesions caused by their denture.²⁵ Regular dental care is essential for maintaining the functional benefits of dentures and the health of the edentulous mouth.

Risk factors and pathophysiology

Dental caries and periodontal disease are the main determinants of tooth loss leading to edentulism. Comorbidities of edentulism include poor nutrition, smoking, diabetes, coronary artery plaque, and rheumatoid arthritis.²⁶ Risk factors for edentulism include poverty and fewer than 12 years of education in non-Hispanic white people (but not in black or Mexican-American people),²⁷ lower original intelligence,²⁸ and increasing age.²⁹

Differential diagnosis and assessment

A detailed intraoral examination should be performed to determine dentate status and condition of any prostheses. Dentures should be removed and tissues examined for oral mucosal lesions. Persons with Candida-associated denture stomatitis and angular cheilitis, traumatic ulcers, and denture irritation hyperplasia should be referred to a dental professional. Questions should be asked of the patient regarding his or her satisfaction with function and comfort.

Management

Complete dentures are the mainstay of treatment for restoring the edentulous mouth. Dentures are not fitted “for life”; they will get looser with time and need regular professional attention. The edentulous ridge (remaining alveolar bone) undergoes continuous resorption over the years, ultimately compromising the fit and stability of the dentures. Only 13% of denture wearers seek annual dental care, and nearly half have not seen a dentist in 5 years.³⁰ Dental-implant–supported dentures may provide more functional capacity than less costly conventional dentures but not every patient is an implant candidate.

Prevalence and impact

Estimates from the American Cancer Society indicated that more than 36,000 individuals would be diagnosed with oral and oropharyngeal carcinoma in 2010.³¹ Of these cancers, approximately 24,000 would be located in the oral cavity proper, excluding the lower lip vermilion and pharynx. Oral cancer incidence increases with age, with the median age at diagnosis being 61 years. Over the last several decades, the incidence rate for men has declined, but it has remained stable in females. Black males have a 30% higher incidence rate than white males for reasons that are not well understood.³²

Despite important advances in the treatment of oral cancer, the 5-year survival rate (approximately 50%) has not changed appreciably in the last 50 years. This is likely related to several factors, the most important of which is the fact that more than 60% of oral cancers are not diagnosed until they are of advanced stage clinically.³²

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