[Review台灣老年醫學 Article] Geriatric Dentistry: Integral Component to 第 3 卷第 3 期 暨老年學雜誌 Geriatric Patient Care

Geriatric Dentistry: Integral Component to Geriatric Patient Care

Chih-Ko Yeh2, Michael S. Katz3, Michèle J. Saunders1,3

Abstract

Geriatric dentistry is the branch of dentistry that emphasizes dental care for the elderly population and focuses upon patients with chronic physiological, physical and/or psychological changes or morbid conditions/ diseases. Oral health reflects overall well being for the elderly population. Compromised oral health may be a risk factor for systemic diseases commonly occurring in age. Conversely, elderly patients are more susceptible to oral conditions due to age-related systemic diseases and functional changes/decay. Oral health evaluation should be an integral part of the physical examination, and dentistry is essential to qualify geriatric patient care. In this paper, we briefly review current issues and topics in geriatric dentistry that reinforce the need for interdisciplinary care/research of the elderly. (Taiwan Geriatrics & Gerontology 2008;3(3):182-192)

Key words: geriatric dentistry, oral health, general health

Introduction integral part of general health. In the elderly population poor oral health has In the U.S. Surgeon General’s first been considered a risk factor for general Report on Oral Health in America, the health problems. On the other hand, older mouth is referred to as a mirror of overall adults are more susceptible to oral health [1], reinforcing that oral health is an conditions or diseases due to an increase in

1 Geriatric Research, Education and Clinical Center, Audie L. Murphy Hospital Division, South Texas Veterans Health Care System, San Antonio, Texas, U.S.A. Departments of Dental Diagnostic Science2 & Medicine3, University of Texas Health Science Center at San Antonio, San Antonio, Texas, U.S.A. Correspondence: Dr. Chih-Ko Yeh GRECC (182), Audie L. Murphy Division South Texas Veterans Health Care System 7400 Merton Minter Boulevard San Antonio, Texas, 78229-4404 Email: [email protected]

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chronic conditions and physical/mental geriatric dentistry and training curriculum disabilities. With advances in oral health content in the United States [3]. In brief, promotion and oral disease prevention in essential topics for geriatric dentistry industrialized countries, more people education include demographic aspects of retain their natural teeth into their old age aging, aging theories and biology, as compared to a half-century ago. The age-related changes in physiology and number of edentulous elderly (>60 years psychology, socio-economic status of the old) in the U.S. has declined to 25% (vs. elderly, common age-related diseases and 56% in 1957); and among the dentate their management, impact of systemic elderly, they have an average number of 19 diseases on oral health and its converse, ± 0.2 teeth [2]. Therefore, dental services oral lesions/pathology in the elderly, for the elderly are shifting from removable treatment planning, delivery of oral health prosthetic-centered care to comprehensive services, nutrition in aging, and geriatric treatment including restorative dentistry, health education/promotion. Geriatric periodontal therapy, oral surgery, dental education should be taught both at , and even cosmetic dentistry, the predoctoral and postdoctoral level to orthodontics and implants. oral health providers, and other health care The dental management of the elderly professionals such as physicians and population is different from that of the nurses, and to caregivers and patients. general population because special In this review, we briefly discuss considerations for age-related current issues and topics in geriatric physiological changes, complications of dentistry. The purpose of this discussion is chronic condition/therapy, increased not to provide specific details on any one incidence of physical/mental disabilities, subject, but rather to emphasize the and social concerns are required. necessity for interdisciplinary approaches Therefore, special knowledge, attitudes, to geriatric patient care. and skills are necessary to provide oral health care to the elderly. Geriatric Effect of Aging on Oral Tissues dentistry, as part of general dentistry, (Gerontology of the Oral Cavity) emphasizes dental care for the elderly population and focuses upon older patients Data on the effect of aging on oral with chronic physiological, physical, tissues are scarce. Often there is no clear and/or psychological changes or disorders. demarcation between normal physiological We have previously reviewed the scope of aging and pathological diseases. Losses of

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translucency and surface details (e.g. changes during aging. However, there may perikymata and imbrication lines) are be some specific changes in individual common changes during aging. , tissues during aging, e.g., salivary gland , and erosion of teeth usually function, taste, tactile sensation and increase with advancing age [4]. The swallowing [8-11]. The clinical dental becomes smaller because of significance of these specific changes is secondary and pulp stone formation, currently unclear. Research in oral health and sometimes root canals become totally during aging is still in an early stage and sclerosed [5,6]. Losses of tooth support further study in this area is necessary. structures (periodontium) are also commonly seen in elderly patients [6,7]. Oral Health and General Health in the An increased loss of epithelium attachment Elderly and alveolar bone in the elderly may be a result of an increase in dental plaque and Oral health has a critical impact on calculus rather than chronic age-related the functional, psychological, and changes per se. It is not known whether economic aspects of the overall quality of older individuals are more susceptible to life. Oral health affects the elderly with periodontal infections compared to other regards to diet and nutrition intake, age groups. As gingival recession psychosocial interaction, and general increases, resulting in exposure of root well-being. The oral cavity is a portal of surfaces to the oral environment, the entry for microbial infections. Common prevalence of root surface caries increases oral diseases such as periodontal diseases in the dentate elderly population. and dental caries are the result of bacterial It should be noted that oral tissues are plaque accumulation. Recent correlation not limited to the teeth and supporting studies have raised concerns about the structures (periodontium) but also include possible linkage between oral salivary glands, , infection/chronic inflammation and orofacial/mastication muscles, systemic disease development/progression oropharyngeal mucosa, and oral (Table 1) [12,13]. Bacteria from the oral sensory/motor nerve systems. Current flora have been recovered from infection studies suggest that oral physiology is sites in other organs of patients with generally intact at older ages. Normally, aspiration pneumonia or endocarditis. A morphologically observed changes in oral recent case report documented a tissues do not cause dramatic functional hemopoietic transplant recipient who

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developed Candida krusei sepsis from factors for oral diseases and conditions. pre-existing oral colonization [14], Multi-pharmacy, physical impairment and suggesting a direct linkage between oral neurological/psychological changes are infection and systemic infection. Oral common among the elderly, resulting in infection-induced chronic inflammation, drug-associated oral diseases/conditions i.e., , has also been (e.g., dry mouth, gingival hyperplasia and associated as a risk factor or predictor for lichenoid reaction) and poor oral hygiene several cardiovascular diseases because due to physical disability and neglect cytokines elicited by oral inflammation (Table 2). might mediate the initiation/progression of Several studies suggested that 68-95% these diseases [12,15]. Establishment of a of persons 65 years or older take causal relationship between oral health and medication. The average number of drugs these systemic diseases is currently an (prescription and/or non-prescription) used emerging research field in geriatrics. by this group is 1.4 to 4.3 [16,17]. With The oral-systemic diseases linkage is physiological aging and multiple a special health concern for the elderly pathologies, elderly patients are more since effective oral hygiene is usually susceptible to drug interactions and compromised in patients with physical and adverse effects [18,19]. One profound side neurological changes. Accordingly, effect of multi-pharmacy is xerostomia elimination of the oral flora burden should (mouth dryness). Saliva is the primary oral be emphasized for geriatric patient care. In defense mechanism in maintaining tooth addition, many systemic diseases and structure against oral infections. Saliva conditions have oral manifestations, which contains multiple antimicrobial factors, may be the initial sign of a number of buffering systems, supersaturated calcium clinical diseases. Oral examination and phosphates, large lubricant molecules, and oral health evaluation should be integrated digestive enzymes. Salivary hypofunction components of a routine physical usually causes rampant and severe oral examination. diseases such as caries and Candida infection. Without adequate salivary Risk Factors Associated with Oral function, quality of life also is likely to be Diseases and Conditions in the Elderly compromised since salivary moisture offers lubrication for taste, speech, Elderly patients, unlike their younger chewing, and swallowing. In addition, counterparts, experience additional risk certain medications commonly prescribed

185 台灣老年醫學 Geriatric Dentistry: Integral Component to 第 3 卷第 3 期 暨老年學雜誌 Geriatric Patient Care

for the elderly can cause enlargement of cognitive deficits of Alzheimer’s Disease gingival tissues (e.g., phenytoin sodium or other dementias lose the ability to and calcium channel blockers) or induce perform proper oral hygiene. Poor oral lichenoid reaction (e.g., hygiene leading to dental infections may in hydrochlorothiazides and ACE inhibitors turn further exacerbate agitation in or angiotensin II receptor antagonists). demented patients and impede medication Although lichenoid lesions of the oral effectiveness in patients with diabetes. mucosa are usually benign and asymptomatic, a very small number of Common Oral Diseases and cases develop malignancy [20]. Today, Conditions in the Elderly with increasing numbers of new therapeutic agents marketed by Similar to the general population, pharmaceutical companies, unexpected caries and periodontal disease remain the oral complications sometimes ensue. As a two major dental problems in elderly possible example, recent reports raise patients (Table 3). As gingival recession concerns that patients undergoing increases, resulting in dental root surface long-term bisphosphonate treatment for exposure to the oral environment, the metabolic bone disease or osteoporosis prevalence of root surface caries increases might be at risk for developing in the dentate elderly population. (called Epidemiological studies in the United bisphosphonate-related osteonecrosis of States showed that more than 50% of older the jaw; BRONJ) [21]. Clinically, individuals (65 years and older) had modification of prescribed medications is experienced root caries [22]. In addition, required for managing drug-related side older persons frequently suffer from effects such as lichenoid reactions or recurrent or secondary coronal caries. In xerostomia in the oral cavity. Additionally, Taiwan as in other industrial countries, the oral disease prevention may be required prevalence of periodontitis and missing for patients prior to prescribing teeth increases with age [23]. bisphosphonates. conditions also are more Age-related disorders themselves prevalent among elderly populations. contribute to higher risks for oral condition Candida infection and denture related in the elderly. Diabetes is a risk factor for lesions are common oral manifestations in advanced periodontal disease and Candida geriatric patients. The oral cavity of infection. Patients who suffer from elderly patients is also vulnerable to viral

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infection (e.g., and Herpes stroke. An alternative treatment plan (such zoster), autoimmune-related disorders as adding fluoride therapy) and instruction (e.g., erosive , should be given to these patients and their vulgaris, pemphigoid), and burning mouth caregiver/family advocates. Likewise, oral (syndrome) due to immune dysfunction, hygiene should be provided as part of nutritional deficiencies, chronic conditions, general hygiene for patients who have and cognitive alterations. The incidence of compromised cognitive function and live oral cancers also increases with advancing in long-term care facilities. Regardless of age. Dentists and other health care dentate status, it is recommended that the professionals should recognize the oral elderly make dental visits at least every six manifestations of these disorders and months for clinical re-evaluation and, provide proper management. depending upon ability to perform oral hygiene for prophylaxis. Those with Special Consideration of Dental Care reduced ability to perform oral self care for Elderly Patients should be seen more frequently for prophylaxis. Since denture-related and Geriatric patients are generally other oral mucosa lesions are common in classified into three groups based on the elderly, edentulous patients should be functional living ability; functionally periodically evaluated by dental independent, frail, and functionally professionals. Further, in the United dependent. Special approaches and States, many states have laws mandating treatment goals for oral health are different annual dental services to residents in for each group [24,25]. Regardless of nursing facilities by licensed dentists functional status, the elimination of acute and/or dental hygienists (e.g., Texas State dental infection and pain should be Senate Bill 34, 2001). achieved for all elderly patients. Oral Geriatric patients usually have at least disease prevention is still the central focus one age-related change and/or disorder that for the elderly population as for other may affect patient management and patient populations. Special oral hygiene treatment planning. Clinical conditions, measures, however, are required for the such as hypertension, anticoagulation elderly. For example, toothbrush or dental therapy, and hypoglycemia, can trigger floss devices with larger handles may be emergency crises during dental treatment. provided to patients with limited manual Patients with diabetes often have dexterity resulting from arthritis and/or cardiovascular diseases and are more

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susceptible to infection if the disease is not weight loss should routinely be recorded properly controlled. Although for dental patients. We have demonstrated controversial, antibiotic prophylaxis may that one-third of physician consultations be necessary for dental procedures in frail resulted in an alteration in dental treatment elders to prevent infection of replaced plans and 8% of consultations led to joints and cardiac prosthetic valves. While commencing medical treatment [27]. dental health care workers provide their While specific health problem professional judgment regarding these management during dental treatment of the special conditions, consultations with elderly remains a real challenge for other health professions are often required dentists, treatment of oral diseases to optimize patient care. All health care themselves is equally challenging. Many providers should be familiar with the treatment modalities are still empirical. treatment guidelines from professional Cervical overhangs are a common problem organizations to facilitate interaction for interproximal restorations due to deep among interdisciplinary care groups [see, subgingival root caries. Dentists should be e.g., the most recent Prevention of aware of advances in dental materials and Infective Endocarditis: Guidelines from new treatment modalities for diseases the American Heart Association (AHA) commonly seen in geriatric patients. [26]]. Unlike the former guideline, the new Hybrid/resin ionomer is a newly developed AHA guideline has limited preventive restorative material that releases fluoride antibiotic use prior to invasive dental and is advocated for use in patients with a procedures in patients with artificial heart high caries risk [28]. Despite years of valve, history of infective endocariditis, effort in the area of prosthodontics, certain specific and severe congenital heart difficult problems remain associated with diseases, and a cardiac transplant with the treatment of full denture patients with valve problem. Oral health providers, as atrophic alveolar ridges. Clinicians and part of the overall health care system, are researchers continue their search for often in the front line in detecting solutions to oral health problems faced by age-related morbid conditions/diseases the geriatric population. through routine oral examination. Medical history and evaluation, as well as vital Conclusion signs, i.e., temperature, respiratory rate, blood pressure, pulse rate and rhythm, as The elderly population is increasing well as presence of pain or significant in industrialized societies worldwide. With

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the decline of caries and periodontal his encouragement and support during the diseases in the younger age groups, dental preparation of this manuscript and Dr. professionals will be expected to take care Howard Dang for his thorough review and of more elderly dentate patients. The critiques of this manuscript. The authors management of the elderly population would like to acknowledge two sources of differs from that of the general population funding from the Bureau of Health because of age-related physiological Professions of the Health Resources and changes, the presence of age-related Services Administration of the United conditions/diseases, increased incidence of States Public Health Service: (1) Geriatric physical and mental disabilities, and also Training Regarding Physicians and social and economic concerns. Geriatric Dentists, 7/1/00-6/30/05, Grant dentistry is a specialized multidisciplinary #5D0-1HP00004; and (2) South, West, and branch of general dentistry designed to Panhandle Consortium Geriatric Education provide dental services to elderly patients. Center of Texas, 7/1/02-6/30/07, Grant Today, oral changes occurring during #D31-HP80001. aging are not clearly understood. Many treatment modalities for geriatric patients Reference are still experimental. Further studies in geriatric dentistry both at the clinical and 1. U.S.Department of Health and Human basic science level are necessary. Oral Services. Oral Health in America: A health is linked to general well being for report of the Surgeon General. (NIH the elderly. Conversely, adverse oral health Publication No. 00-4713). 2000. has been identified as a risk factor for Rockville, MD, U.S. Department of several systemic disorders/diseases. Dental Health and Human Services, National care should be integrated into overall Institute of Dental and Craniofacial health management of all geriatric Research, National Institutes of Health. patients. 2. Centers for Disease Control and Prevention (CDC). Retention of natural Acknowledgement teeth among older adults − United States, 2002. MMWR 2003; 52: The authors would like to thank 1126-229. Liang-Jiunn Hahn 韓良俊 (Professor 3. Yeh CK, Hou LT, Katz MS, Saunders Emeritus, School of Dentistry, College of MJ: Geriatric dental education and Medicine, National Taiwan University) for training in the United States of

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