Geriatric Oral Health.pdf

Geriatric Oral Health.pdf

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  The geriatric populationis the most rapidly growing segment of the population. Aging and systemic diseases and their treatments can influence oral health and function, and it is important for clinicians to be able to recognize, diagnose, and treat oral conditions in the elderly. The purpose of the American Academy of Oral Medicine Oral Health in Geriatric Patients is to provide a summary of the influence of aging, systemic disease, and its treatment on oral health. This guide will also provide a summary of the etiology, clinical appearance, and treatment of common oral conditions that affect older populations. Topical and systemic drug regimens are provided for the management of common oral disorders. It is important to remember that the pharmacokinetics of drug absorption, distribu- tion, metabolism, and excretion are altered in the elderly, and therefore the clini- cian should consider changing drug regimens or dosages depending upon con- comitant drug therapy, renal and liver function, and the potential for adverse drug reactions. THE GERIATRIC POPULATION The aging population is the most rapidly growing segment of most developed countries. In 1950, only ~10% of the US population was aged 65 years or older. This value increased to 13% in 1997 and is expected to reach 20% by the year 2030. These demographic trends are even more remarkable for very old adults: individuals aged 85+ years will undergo nearly a threefold increase in the next 35 years. In comparison with statistics from 1900, the population has changed dra- matically around the world. For example, the median age of death has reached 80 years in the United States (in 1900, the value was 58 years) and 1.5% of the pop- ulation survives to age 100 (in 1900, the value was 0.03%). Although most of the world’s elderly population live at least partially independ- ent lives, a significant number of older adults are completely dependent for all aspects of life. For example, over 6% of adults in the United States over age 65 years are in nursing homes, currently exceeding 2 million persons. Nursing home residents have more than doubled since 1965, and US nursing home beds exceed hospital beds. The lifetime risk for institutionalization is 52% for females and 1 ORAL MEDICINE AND GERIATRICS Ship_folio 3/14/06 2:36 PM Page 1
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  30% for males.These trends in the aging population, both community-dwelling independent and institutionalized, have profound implications for oral health, including the status of the natural dentition. Oral health is particularly important among the elderly. Older adults are more susceptible to systemic conditions, predisposing them to develop oral and max- illofacial diseases that can directly or indirectly lead to malnutrition, altered communication, increased susceptibility to infectious diseases, and diminished quality of life. Age alone does not seem to play a major role in impaired oral health. Rather, oral diseases (eg dental caries, gingivitis and periodontitis, oral mucosal diseases, sali- vary dysfunction, alveolar bone resorption), systemic conditions (eg, diabetes, stroke, Alzheimer’s disease), prescription and nonprescription medications, and head and neck radiotherapy predispose older persons to developing oral and pharyngeal disorders. The effects of stomatologic diseases are not limited to the oral cavity and its functions. Oral diseases give rise to pathogens, which can be bloodborne or aspirated into the lungs, bringing about severe, even life-threat- ening consequences. Systemic mucocutaneous and dermatologic diseases can manifest initially in the oral cavity, which can predispose older individuals to additional oral and pharyngeal problems. Today’s older adult is more likely to have natural teeth compared with previous aged cohorts. Thus, older persons are currently at higher risk of developing a serious dentally derived systemic disease than earlier cohorts of elders. In addi- tion, older adults are more likely to utilise dental health care services and per- form regular oral hygiene compared with previous older generations. Therefore, the dental profession must be able to diagnose, manage, and ultimately prevent oral diseases that may increase morbidity and mortality among the elderly. TEETH The most common age-related changes in teeth include occlusal attrition, pulpal recession and fibrosis, and decreased cellularity. Secondary and reparative dentin contribute progressively to acellular and dehydrated dentin. Hypercementosis is a response to trauma, caries, and periodontal diseases.With greater age, teeth under- go staining, chipping, and cracking and become more susceptible to fracture. Older people are at risk of developing new and recurrent coronal caries, and they are more likely to have root surface caries compared with younger adults. Dental caries is the most common cause of tooth loss in the elderly, accounting for more extractions than periodontal diseases. Gingival recession, salivary gland hypo- function, less effective oral hygiene, and diminished oral motor function all con- tribute to root surface caries. Removable prostheses also increase susceptibility to root surface decay. A greater retention of the dentition among the elderly com- bined with large restorations places coronal surfaces at risk of decay as well. 2 Oral Health in Geriatric Patients Ship_folio 3/14/06 2:36 PM Page 2
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  Oral Medicine andGeriatrics 3 Caries treatment in the elderly does not differ dramatically from that of younger patients. Fluoride-releasing restorative materials (glass ionomers) are particular- ly useful for root surface decay and in patients with a dry mouth. Composite resins are indicated for repairing defective restorations and/or carious tooth sur- faces, while the new generation of glass ionomer liners provides sustained fluo- ride release that reduces the incidence of recurrent caries. An assessment of caries risk is advised for all patients; risk factors found in the geriatric population include use of multiple medications (especially medications that inhibit salivation), gingival recession, and poor oral hygiene secondary to debilitation. Dental caries and subsequent tooth loss can be prevented in high- risk patients with regular recall; application of topical fluoride rinses, gels, and varnishes; appropriate oral hygiene; and early intervention of salivary dysfunc- tion. Older patients with cognitive and/or motor disturbances usually require daily assistance to maintain the health of their dentition. PERIODONTAL TISSUES Gingival recession and loss of periodontal attachment and bony support are essen- tially universal in most older persons. Yet changes in the periodontium attributed solely to age are not sufficient to lead to tooth loss. Nevertheless, because multiple oral factors, systemic diseases, and medications have an adverse influence on peri- odontal health,and because these conditions are more prevalent among older adults, it is the older population that is at risk of experiencing periodontal disease–related morbidity. For example, patients with diabetes have a higher prevalence and severity of periodontal diseases. Several medications frequently prescribed in older people have been associated with gingival enlargement: antihypertensive calcium channel blockers, the antiseizure drug phenytoin, and the immunosuppressant cyclosporin. Periodontal diseases have oral and systemic effects on the health of older persons. They have been associated with halitosis, gingivitis, and tooth loss, which can affect mastication, swallowing, tasting, and nutritional intake. Periodontal dis- eases have also been associated with cardiovascular, cerebrovascular, endocrine, pulmonary, and infective diseases. The treatment of periodontal diseases among the elderly is similar to that for younger patients. Although wound healing may take slightly longer, ultimate disease resolution can be obtained with appropriate interventional therapy and regular oral hygiene. Patients with bleeding disorders, extensive cardiopulmonary problems, and immunosuppression may be poor candidates for periodontal surgery; local methods (extensive scaling/root plan- ing), topical drugs (antimicrobial and anti-inflammatory agents), and occasion- ally systemic drugs (antimicrobial and anti-inflammatory agents) are preferred. ORAL MUCOSA Both normal aging changes and pathologic factors contribute to oral pathoses. Stratified squamous epithelium becomes thinner, loses elasticity, and atrophies Ship_folio 3/14/06 2:36 PM Page 3
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  with age, whiledeclines in immunologic responsiveness increase susceptibility to infection and trauma. Increases in the incidence of oral and systemic diseases and the use of multiple medications lead to oral mucosal disorders among the elderly. The oral mucosa is a common site for vesiculobullous, desquamative, ulcerative, lichenoid, infectious, and malignant lesions. For example, many older adults are at risk of developing oral fungal infections, which, when diagnosed appropriately, can frequently resolve with topical therapies. Oral cancer is prima- rily a disease of adults aged 50 years and older, which has only 50% survival at 5 years, owing in part to late diagnosis. Any mucosal lesion that persists for 3 to 4 weeks despite all attempts to remove suspected etiologies (eg, ill-fitting denture flange) must be thoroughly investigat- ed to determine a diagnosis (eg, biopsy). Regularly scheduled periodic head, neck, and oral examinations are required to diagnose oral mucosal diseases at an early stage and to intervene with appropriate therapy. Importantly, even edentu- lous older adults require at least an annual head, neck, and oral examination to evaluate for benign and malignant lesions. SALIVARY GLANDS Research studies have demonstrated that in healthy older adults, there is no gen- eral diminution in the volume of saliva produced. However, many older persons complain of a dry mouth (xerostomia) and have diminished salivary output (salivary hypofunction). Systemic diseases, medications, and radiation therapy for head and neck tumors most likely cause these problems. Over 400 drugs have been reported to decrease salivary flow, especially tricyclic antidepressants, seda- tives and tranquilizers, antihistamines, antihypertensives, cytotoxic agents, and anti-Parkinson drugs. Diseases such as Sjögren’s syndrome, other autoimmune conditions, diabetes, and Alzheimer’s disease can also cause salivary disorders. Salivary hypofunction leads to numerous oral and pharyngeal problems in the older adult: dry and friable oral mucosa, decreased antimicrobial activity, dimin- ished lubrication, caries development, oral fungal infections, pain, difficulty with mastication, deglutition, gustation, and impaired retention of removable pros- theses. Therefore, early diagnosis and intervention are necessary to prevent the deleterious sequelae of a dry mouth. Diagnostic procedures include a careful review of the patient’s history and physical findings, sialometry, sialograms, labi- al gland biopsies, and 99m Tc pertechnetate scintiscans. Consultation with patients’ physicians may help change drugs or drug dosages associated with xerostomia. Salivary substitutes; frequent oral hygiene; gustatory, masticatory, and pharmacologic salivary stimulants; and long-term fluoride therapy are required to maintain oral and pharyngeal health for the lifetime of the patient. 4 Oral Health in Geriatric Patients Ship_folio 3/14/06 2:36 PM Page 4
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  ORAL MOTOR ANDSENSORY FUNCTION Alterations in mastication, swallowing, and oral muscular posture occur with aging. The most often reported oral motor disturbance in older people is altered mastication, and even fully dentate older persons are less able to prepare food for swallowing as efficiently as younger adults. This altered masticatory ability may not have any adverse effects on a healthy older person; however, systemic diseases (eg, strokes, Parkinson’s disease) and drug regimens (eg, association between tar- dive dyskinesia and phenothiazines) common in the elderly can cause significant effects on chewing and swallowing, predisposing these persons to choking or aspiration. Other age-related diseases such as osteoarthritis may affect the tem- poromandibular joint (TMJ), yet the elderly are less likely to report symptoms of TMJ-related pain. Many older adults complain of diminished food recognition and enjoyment, as well as altered smell and taste function. Research studies have demonstrated that whereas taste function undergoes relatively few age-related changes, smell is dra- matically diminished across the human life span. Decreased smell capacity com- bined with changes in oral motor, salivary, and other sensory modalities most likely accounts for the loss of flavor perception and interest in food in older per- sons. Medically compromised older adults suffering from these problems require nutritional counseling to prevent malnutrition, dehydration, and a diminished quality of life. ADDITIONAL READINGS Abrams WB, Beers MH, Berkow R, editors. The Merck manual of geriatrics. 3rd ed. Rahway: Merck and Co, Inc; 2000. Barnes IE, Walls A, editors. Gerodontology. Oxford: Wright; 1994. Hayslip B, Panek P. Adult development and aging. 3rd ed. Malabar: Krieger; 2002. Hazzard WR, Blass JP, Halter JB, et al, editors. Principles of geriatric medicine and gerontology.5th ed. [In press] Holm-Pedersen P, Löe H, editors. Textbook of geriatric dentistry. 2nd ed. Copenhagen: Munksgaard; 1996. Oral Medicine and Geriatrics 5 Ship_folio 3/14/06 2:36 PM Page 5