The challenges for prevention with an ageing population: Part 1. Focussing on the patient

By Emeritus Professor Laurence J. Walsh AO

Across Australia and New Zealand, the ageing population is posing considerable challenges to health insurance, availability of places in residential aged care, workforce demands in residential aged care, rising demand for hospitalisation and changing patterns of oral

health care.

This is impacting on the professional lives of not only the oral health workforce but all those involved in the wider health system. This article is the first part of a series that explores issues around managing elderly patients.

The perfect storm?

Reduced levels of complete edentulism and greater retention of natural teeth have created a situation where the demands for maintenance of the natural dentition, to address issues such as root surface caries and destructive periodontitis, are rising.

At the same time, there is increasing demand to maintain dental implants and prostheses of various types and reduced demand for replacement of complete dentures. Today, many patients expect to keep most of their natural teeth. Having more dentate elderly patients who have greater medical complexity creates a perfect storm.

If one looks at the demographics for both Australia and New Zealand, the steady growth in population has been accompanied over the last 40 years by an increase in life expectancy and in the median age of the population. Taking data for both countries together, life expectancy at birth for men has risen from 73 years in 1991 to over 80 years in 2021 and for women from 79 years to 84 years. A greater proportion of the population is now in the older age groups, particularly due to the “baby boomer” group. Over the next 10-12 years, around one quarter of the ANZ population will be aged 65 years or more and around one in eight people will be 75 or more.

A patient’s physical well-being and medical status will impact their quality of life, as well as and their ability to undertake activities of daily living (ADLs) (Figure 1B). Age-related reductions in hearing, vision, short-term memory, mobility and dexterity mean that more support is needed for performing activities of daily living, especially for those who are aged 85 years and above. As well as the accumulated effects of ageing that could be described as normal wear and tear, many systemic conditions are more prevalent in the elderly and a patient’s oral health can be impacted directly by systemic disease as well as by medications that are used to manage or treat those conditions. Salivary gland hypofunction is common in elderly patients because of polypharmacy (Figure 1C,D).

Rising pill burden and its consequences

There are many challenges that surface when individuals live for longer. It is common to see that elderly patients are being managed for hypertension and arthritis, as these are the two most common conditions in elderly individuals across the ANZ region.

Panel A: Greater medical complexity in elderly patients comes with a larger “pill burden” and an increased likelihood of adverse drug reactions as well as salivary gland hypofunction.

Panel B: The ability to open a pill bottle is a quick test for manual dexterity. A person who cannot do this will likely struggle with toothbrushing.

Panel C: Typical frothy white saliva on the soft palate indicating salivary gland hypofunction.

Panel D: Saliva test results from the GC SalivaCheck Buffer test kit that raise concerns of salivary gland disease. The upper part shows the buffer test pads. The buffer capacity is unusually low. The lower left strip shows an acidic resting salivary pH, while the lower right strip shows that the pH of the stimulated saliva is below the normal range.

Panel E: Typical appearance of neglected oral hygiene in a nursing home resident.

Panel F: A broken down dentition in a dependant patient who has been living in a nursing home. The incisal edges show erosive destruction.

Panel G: various toothbrush modifications to make the brush handle easier to hold.

Panel H: A laptop and intraoral camera used for teledentistry remote oral assessments. The image shows Dr Candy Fung from the UQ special needs dentistry program who has been conducting teledentistry in nursing homes.

Prescription medicines used to manage hypertension can cause a range of impacts on oral health, including salivary gland hypofunction (beta-blockers), gingival overgrowth (calcium channel blockers) and unprogrammed coughing (ACE inhibitors) as common examples. Knowing which medicines patients take and why they take them, is essential for safe and effective oral health care provision (Figure 1A).

As the total pill burden of an elderly patient increases, so does their risk of developing adverse oral changes as a result of polypharmacy. Many elderly patients will show reduced production of saliva at rest (Figure 1C), with an increase in the risk for dental caries, dental erosion, cervical dentinal hypersensitivity and oral fungal infections. The acidic oral environment in these patients poses a major challenge for effective dental maintenance.

A key element of the successful oral health management of elderly patients is to correctly chart their medical trajectory and take note of medical events, medical conditions and medications that can adversely impact oral health. It is important not to just focus narrowly on “the pills that they are taking” and which are presented in a pill organiser. One must also ask about medications they are having in ways other than in pills that are swallowed (e.g. inhalers, patches, injections). One must also ask about over-the-counter medicines purchased at a pharmacy and about alternative health products, as both are very commonly used.

For elderly patients, processes around absorbing, distributing, metabolising and excreting drugs are impaired, due to reduced liver function and kidney function, amongst other things. As a result, the therapeutic window (the concentration range where the drug is safe and effective) is much narrower than in a young patient. This means that drugs are more likely to accumulate and cause toxic effects in elderly patients because they are not cleared or metabolised very well. Adding to this, many elderly patients have a low body mass and this must be taken into account whenever considering what the toxic dose may be (e.g. for dental local anaesthetics).

Rapid oral health decline

Caring for individuals who have invested much effort and expense in retaining their natural teeth becomes espe- cially challenging when those individuals are no longer able to perform their own oral care. Because of greater retention of teeth, there is a large surface area that must be managed during regular tooth cleaning and this can pose a great challenge to a patient - and even more so to a carer who is trying to perform oral hygiene for them.

As the oral hygiene standard collapses (Figure 1E), the dentition deteriorates, with dental caries and periodontitis being major drivers of tooth loss. Unmanaged conditions such as reflux are common in elderly patients and this can also cause substantial loss of tooth structure (Figure 1F).

Contributing factors

The oral health of an elderly patient will often change suddenly for the worse when they move from living at home to a supported living environment. The key drivers are the changes in their lifestyle and diet, with a much higher frequency of exposure to preprepared food with a high load of carbohydrates. When this is combined with a requirement for nursing home staff to assist with tooth cleaning, it is common to see a downward spiral in oral health, which is often termed rapid oral health deterioration (ROhD).

This becomes a tipping point in terms of the survival of the dentition. Teeth can become ring-barked by caries and the unsupported crown then breaks off, leaving a root stump behind.

Often a trajectory of decline begins after some major life changing event which makes the patient suddenly more frail and less able to care for themselves. Other important triggers can include the loss of a partner and a move from independent living in the community to living in a residential aged care facility (RACF). Hence, when tooth loss now occurs, it is in the context of

Comorbidities

Most large studies of elderly cohorts in Australia and New Zealand report that around 50% of men or women over the age of 65 suffer from arthritis. This can affect their general mobility, as well as their manual dexterity. The latter will influence their ability to use a conventional manual toothbrush effectively. A range of modifications can be undertaken to make the brush handle easier to hold (Figure 1G).

significant personal loss that has already occurred (loss of the partner, loss of independence and greater reliability on others).

The loss of teeth affects the ability to chew and alters the way that patients select foods. This, in turn, affects their nutrition and their general health. It is important to realise that effective oral health care must not only aim to support a dentition which is comfortable and free of pain, but also one that can provide sufficient function in terms of chewing nutritious foods. In some situations, the shortened dental arch approach can be very useful because it reduces the complexity for tooth cleaning, yet maintains the patient’s ability to eat a suitable range of foods.

There is a great opportunity for dental professionals to educate carers and nursing staff in RACF, both on-site and also through teledentistry (Figure 1H). Both can improve their ability to undertake oral health assessments using standardised tools (such as the oral health assessment tool, OHAT) and to correctly identify when patients require a dental referral to address an oral health issue. Such tools help in care planning for residents, as well as in communication between nursing home staff and external clinicians.

Rating dependency

Based on the need for support and their ability to undertake ADLs, a useful way to think about elderly patients is to classify them in terms of their dependency. Robust patients can do a full range of

ADLs and typically live in the community in an independent way with little if any restrictions on their life. A person with low dependency is using an aid like a walking stick or walking frame, to enhance their mobility, but otherwise is independent for many aspects of living. The third category are patients with high dependency who are typically described as being medically frail. These patients need support for most or all of their activities of daily living, even the basic most basic ones, such as personal hygiene and oral care. Individuals can reach this last stage through a gradual trajectory of decline from health through to frailty through to dependency. Alternatively, they can progress quickly from health through to dependency because of a single serious event, such as a stroke or a major fall or accident. They suddenly become frail and now will live the remainder of their life with a significant disability.

The next article will explore some of the more common medical issues faced by elderly patients and how these influence the safe provision of oral health care.

About the author

Emeritus Professor Laurence J. Walsh

AO is a specialist in special needs dentistry who is based in Brisbane, where he served for 36 years on the academic staff of the University of Queensland School of Dentistry, including 21 years as Professor of Dental Science and 10 years as the Head of School. Since retiring in December 2020, Laurie has remained active in hands-on bench research work, as well as in supervising over 15 research students at UQ who work in advanced technologies and biomaterials and in clinical microbiology. Laurie has served as Chief Examiner in Microbiology for the RACDS for 21 years and as the Editor of the ADA Infection Control Guidelines for 12 years. His published research work includes over 390 journal papers, with a citation count of over 18,300 citations in the literature. Laurie holds patents in 8 families of dental technologies. He is currently ranked in the top 0.25% of world scientists. Laurie was made an Officer of the Order of Australia in January 2018 and a life member of ADAQ in 2020 in recognition of his contributions to dentistry.