By Zara Risoldi Cochrane, PharmD, MS, FASCP

September 2018

Long-Term Care Updates

A report recently published by Oral Health America has brought increased attention to the status of oral health in older

adults across the nation. The nonprofit organization released their fourth edition of A State of Decay, an investigation

which ranks each of the 50 states of the basis of oral health in adults aged ≥65 years. Among the findings from this report

is the fact that one-third of older adults have severe tooth loss, defined as the loss of six or more teeth due to disease or

decay.1,2

To perform their analysis, Oral Health America evaluated state-level data on six domains related to oral health: prevalence

of severe tooth loss; proportion of patients with a dental visit in the previous 12 months; extent of Medicaid coverage for

dental benefits in adults; prevalence of community water fluoridation; extent of a statewide plan to improve oral health;

and whether a state conducts basic screening surveys related to oral health.1,2 On the basis of these performance

measures, 26 states earned a poor overall score in the 2018 report, with Mississippi coming last in the nation. The Figure

on page 2 displays each state's ranking with respect to oral health status in older adults.

While many of the evaluation criteria reflect systemic issues, such as access to and utilization of dental care, patient-specific

factors were also highlighted in the report. Older women were more likely than older men to have visited a dentist in the

previous 12 months, and also reported lower rates of severe tooth loss. Patients with a higher level of formalized

education had better oral health. When compared to married individuals, older adults who were divorced or widowed

were more likely to have poor oral health.2

Despite the overall findings of A State of Decay, tooth loss and poor oral health can be avoided in many older adults. The

article that follows will review the impact of age-related changes as well as the connection between oral and overall health.

Next month's edition will address the impact of medications on oral and dental health.

Figure. Overall State Rankings for Oral Health in Older Adults

PoorFairGoodExcellent

Age-related changes to physiology may predispose older adults to oral health concerns. Gingival recession increases with

age, putting older adults at an increased risk of root caries (cavities that affect the root of the tooth).3 Root caries are a

common cause of tooth loss, and are seen in half of all patients aged 75 years or older.3,4

Older adults may experience changes in salivary composition and vasoconstriction of the salivary glands. These changes,

along with the use of certain medications, predispose elderly patients to xerostomia (dry mouth). Xerostomia can in turn

lead to other oral health complications, such as mucositis, caries, cracked lips, or fissured tongue.3 Xerostomia also

contributes to bad breath and can impair normal functions such as speaking, chewing, and swallowing.4

Age-related declines in central nervous system (CNS) function cause many elderly patients to exhibit an exaggerated

response to CNS drugs. This includes agents commonly used in dental surgery and procedures, such as benzodiazepines,

local and general anesthetics, and opioids.3

Fast Facts About Oral Health in Older Adults3-7

Older adults are developing dentalcaries at a rate greater or equal tothat in children:

■ 18% of those aged ≥65 years haveuntreated caries

■ 50% of those aged ≥75 years haveroot caries

68% of patients aged ≥65 years have periodontitis (gum disease)

30% of patients aged ≥65 years are impacted by xerostomia (dry mouth)

Adults aged ≥65 years have an averageof 9.24 decayed or missing permanentteeth:

■ 25% of those aged ≥75 years haveedentulism (complete tooth loss)

In addition to physiologic changes, increasing age is associated with concomitant conditions which impact oral health.

Diabetes, Alzheimer's disease, and Parkinson's disease may contribute to xerostomia. Conditions such as diabetes can

worsen oral health by making patients more susceptible to microbes and other sources of infection.4 Patients with dementia

or severe cognitive impairment have a decreased ability to independently perform regular oral hygiene, increasing their risk

of caries, periodontal disease, and oral infection.3 Furthermore, conditions that impact the mobility of a patient's hands, arms,

or neck, such as osteoarthritis or rheumatoid arthritis, can impede the ability to use a toothbrush or other dental tools.3

In addition to the teeth’s role in digestion, the oral cavity is responsible for a number of health-related functions. The lips,

tongue, and throat interact with external stimuli, send signals to the central nervous system regarding food and other

ingested materials, filter microbes and antigens, and facilitate speech.4 Thus, oral health is linked to a patient’s overall

health and well-being.

Research has demonstrated that patients with poor oral health have an increased risk of diabetes, stroke, heart disease,

pulmonary disease, and other serious health concerns.7 Periodontal disease is associated with atherosclerosis, although a

causative relationship has not been established. Poor oral health has also been associated with functional disability and

decline.4

Plaque and biofilm in the mouth can act as a reservoir of respiratory pathogens. Microbes from the oral cavity may be

transported into the respiratory tract, promoting infection or exacerbating conditions such as chronic obstructive

pulmonary disease (COPD).4 Appropriate oral hygiene can reduce the risk of aspiration pneumonia.7

Oral health is also closely linked to nutritional status. In many cases, older adults with poor dental or oral health cannot

consume a normal diet. They may select soft, easy-to-chew items and avoid protein, fibrous fruits and vegetables, and

other nutrient-rich foods.4,7 This altered food intake is frequently due to tooth loss, use of dentures, periodontal disease,

or xerostomia.4 Soft foods often contain higher amounts of sugar, carbohydrates, saturated fats, and cholesterol, and

lower amounts of vitamins, trace minerals, and fiber.4,9

In addition to physical complications, a patient’s oral health may influence their social health. Poor oral hygiene can lead to

halitosis, unwanted cosmetic changes, or the inability to eat normally, all of which affect self-image.4 Loss of teeth may

impair speech and prevent a patient from smiling.9 These complications may in turn lead to social isolation and contribute

to depression.4 Therefore, oral health and dental hygiene are important components of a patient’s

overall health maintenance.

Additional recommendations for the maintenance of oral health in older adults are as follows:3,4,8,10,11

■ Patients with impaired mobility or dexterity may benefit from using an electric toothbrush, or from modifying a

toothbrush handle so that it is wider and easier to grasp. (For example, the handle of a manual toothbrush can be

wrapped in a washcloth or inserted into a tennis ball or bicycle handle.) Electric toothbrushes require less

movement of the wrist and are more effective at removing plaque than manual toothbrushes.

■ For patients with gum recession or periodontitis, recommend a toothpaste designed for sensitive teeth. The

abrasives in regular toothpaste are too rough for the layers of tooth that are exposed when gums recede.

■ Patients who have difficulty swallowing may use less toothpaste or none at all. The act of brushing mechanically

removes food particle and plaque from teeth.

■ Mouthwashes that are alcohol-free or formulated for dry mouth are generally preferred in older adults.

■ Removeable dentures require special tools for dental hygiene, including denture brushes and minimally abrasive

cleansers. In addition to soaking and cleaning their dentures, patients should cleanse their mouth and gums each

evening with a wet washcloth to remove denture adhesive, food particles, and bacteria.

National and state-level data suggests that older adults are receiving inadequate care related to oral health. Age-related

physiological changes predispose elderly patients to gum disease, root caries, and xerostomia. Poor oral health leads to

complications in overall health and well-being. Consultant pharmacists can positively impact oral health in older adults by

recommending appropriate strategies for dental care and by helping to select appropriate over-the-counter products

related to dental hygiene.

http://creighton.edu/pharmerica

1. Schu C. Announcing OHA’s National Oral Health Report: A State of Decay. Oral Health America Web site. April 17,2018. https://oralhealthamerica.org/blog/2018/04/announcing-ohas-national-oral-health-report-a-state-of-decay/.Accessed August 7, 2018.

2. Evans CA, Kepler Cofano L, Brunner TD, et al. A State of Decay: Are Older Adults Coming of Age Without OralHealthcare? Volume IV. Oral Health America Web site. 2018. https://oralhealthamerica.org/wp-content/uploads/AStateOfDecay2018_OHA.pdf. Accessed August 7, 2018.

3. Aging and Dental Health (Geriatrics). American Dental Association Web site. Updated January 2, 2018.https://www.ada.org/en/member-center/oral-health-topics/aging-and-dental-health. Accessed August 7, 2018.

4. Shuman S, Chen X, Friedman PK, Ghezzi EM, Saunders MJ, Wu B. Oral Health: An Essential Element of Healthy Aging.The Gerontological Society of America Web site. https://www.geron.org/images/gsa/documents/oralhealth.pdf.Accessed August 7, 2018.

5. Division of Oral Health. Oral Health for Older Americans. Centers for Disease Control and Prevention web site.Updated May 2, 2018. https://www.cdc.gov/oralhealth/basics/adult-oral-health/adult_older.htm. Accessed August 20,2018.

6. Dental Caries (Tooth Decay) in Seniors (Age 65 and Older). National Institute of Dental and Craniofacial Research Website. Updated July 2018. https://www.nidcr.nih.gov/research/data-statistics/dental-caries/seniors. Accessed August 20,2018.

7. Research America. Oral Health in Older Adults Fact Sheet. Oral Health America Web site.https://oralhealthamerica.org/wp-content/uploads/ResearchAmerica-OralHealthInOlderAdults.pdf. Accessed August 20,2018.

8. Wisdom Tooth Project. Daily Oral Hygiene Tips. Oral Health America Web site. http://oralhealthamerica.org/wp-content/uploads/Daily_Oral_Hygiene_Tips.pdf. Accessed August 20, 2018.

9. Gregory D. The Connection of Common Health Problems to Your Mouth. Oral Health America Tooth Wisdom Website. 2018. https://www.toothwisdom.org/a-z/article/mouth-body-connection/. Accessed August 20, 2018.

10. Downing Gould E. Tooth Brushing Tips for Older Adults. Oral Health America Tooth Wisdom Web site. 2018.https://www.toothwisdom.org/a-z/article/toothbrushing-tips-for-caregivers/. Accessed August 20, 2018.