Family physicians focus on preventive care to help people get well, stay well and avoid potential complications at every stage of life. Comprehensive oral health preventive medicine for older adults is essential and should include: Assessment, education, and referrals for older adults. Visits to the dentist may not be part of the older patient’s routine care due to the lack of dental benefits, exacerbated by low income, disability, mobility, and racial and ethnic disparities. The medical provider may offer the only oral health evaluation an older adult receives. The mouth reflects general health and well-being. This article reiterates general health risk factors common to many diseases, such as tobacco use and poor dietary practices, which also affect oral and craniofacial health. Oral health means more than healthy teeth and the absence of disease. It involves the ability of individuals to carry out essential functions such as eating and speaking, as well as to contribute fully to society.
Access to dental services is especially difficult for those most vulnerable; this is particularly true for low-income, older adults. Barriers to dental services for the adult over the age of 65 are complex, among the most prominent are a general decline in health, the ability to access oral healthcare services, transportation, lack of knowledge, and a lack of dental insurance. Medicare does not include any routine dental services. To add dental to the Medicare benefit there needs to be a legislative change to the Social Security Act. As a result of Section 1962 (a)(12) of the Social Security Act, beneficiaries are not entitled to Medicare dental coverage, particularly in the case of routine checkups, dental cleanings, cavity fillings, tooth extractions, and dentures. This exclusion from Medicare was not determined by the value or necessity of dental care, but rather by the type of service being provided and anatomical structure involved.
It appears to be more important for the older adult with limited access to dental services and multiple morbidities to use preventive oral health home care, including education for family caregivers on an oral health care plan to prevent disease. This may include special holders for toothbrushes to accommodate adults with arthritis, recommendations for electric toothbrushes, three sided toothbrushes, special holders for flossing, and fluoride. Many older adults have had crowns, bridges, and other restorations they want to maintain along with their natural teeth. Fluoride can save the teeth and any prior investment in dental care by preventing decay.
Maintaining a healthy mouth may be more complex for the older adult due to chronic disease issues. When the physician is treating and monitoring the patient the healthcare professionals in the practice could assist with appropriate recommendations. Many older adults experience poor oral health associated with multiple chronic health conditions such as periodontitis which has been found to be linked with diabetes, and heart disease. More recently, many chronic aging conditions are under study for determining an association with poor oral health. Medications patients are prescribed may cause xerostomia reducing the buffering effects of saliva. Many older adults have inadequate knowledge about oral-systemic health factors especially lower income, rural and less educated older adults. A flyer with more information for the older adult patient and the systemic connection of oral health and overall health accompanies this newsletter.
As research continues more will be known about the association of poor oral health with overall health. Duke University did a study on the association between dementia and number of teeth. While the Duke University researchers can’t say there’s enough evidence to say one causes the other, there appears to be a link between the number of teeth and periodontal disease with the risk of cognitive decline or dementia. Researchers reviewed 56 studies published between 1993 and 2013 and found evidence suggesting older people with cognitive impairment, such as dementia, are more likely to have oral health problems. The researchers do suggest more research is needed, but this is another possible link to oral health. As more research is done, the association between overall health and oral health may continue to demonstrate the significance of good oral health in all populations.
Nutritional intake for the older adult is an important concern for physicians. Literature has documented edentulism, tooth aches, and poorly fitting dentures cause individuals to forgo nutritious food choices such as fruit and vegetables due to an inability to chew properly. Older adults who suffer from edentulism are known to modify their dietary practices to match their new mastication abilities and tolerance levels. Reduced consumption of essential nutrients and fiber deprive older adults of nutritional health benefits, rendering them more vulnerable to disease. While advancing age impairs the sense of taste, diseases, medications, and dentures can also contribute to this sensory loss. It is important to have a discussion with the older patient about any dietary changes due to oral discomfort. The physician may prevent any nutritional insufficiencies before they occur. Family physicians can help the patient understand the importance of good oral health and refer to dentists for routine care.
What to look for:
- Plaque – poor brushing or flossing.
- Reddened gums – gingivitis and recession.
- Dry mouth – the main function of saliva is not, as is commonly believed, to aid digestion, but to protect the integrity of the oral tissues. The lack of saliva may contribute to poor oral wound healing.
- Complaints about sensitivity due to recession – special toothpastes help but need to be used daily. Once the toothpaste begins to work people often switch and these work as a protective screen. Fluoride varnish helps protect the tooth from decay and reduces sensitivity due to recession and root exposure.
- Broken teeth and root fragments that require a referral.
- TMJ Disorder or discomfort – many older adults have bone and joint diseases. It may be likely that some temporomandibular joint disorders are factor related to osteoarthritis, rheumatoid arthritis, or myofascial pain. People with osteoporosis may have TMJ disorders and increased risk factors for Periodontitis and alveolar bone loss.
- Broken fillings – requiring replacement, and may present as tooth sensitivity due to saliva contact with pulp.
- Cavities at the gum line where root is exposed.
- Red areas where the denture rubs.
- Oral Cancer – oral and pharyngeal cancers are diagnosed in about 30,000 Americans annually; these cancers are often diagnosed in the elderly. Prognosis is poor if not caught early.
- Oral thrush, oral candidiasis – can be found under the denture.
Older Americans are retaining their teeth more than ever before and remain subject to oral diseases and disorders. With more teeth at risk, there will be an increase in coronal and especially root caries among the elderly, as well as periodontal diseases.
The 2011 Institute of Medicine report Advancing Oral Health in America called for enhancing the role of non-dental health care professionals in an effort to reduce oral health disparities. There is great potential for physicians to improve access to needed oral health care services for the older adult by emphasizing disease prevention and oral health promotion, improving oral health literacy, reducing oral health disparities, and enhancing the role of non-dental health care professionals.
The following flyer from the Georgia Oral Health Coalition may be a helpful resource for physicians discussing oral health with older adult patients.