Chapter 12 - Oral health of older people

Chapter 12 Oral health of older people Janet Griffiths

It is a well known fact that the UK population is ageing. The Government’s projections suggest that by 2020, the population will reach 63.9 million and peak in 2040 at around 66 million. The proportion of older people is expected to rise. Although the ‘baby boomers’ of the 1940s and 1960s are an important factor, the main reasons are longer life expectancy and a fall in mortality in older age groups. Over the next few years, the increase in numbers of old and very old people in society will exceed that for the population as a whole. By 2020, more than 12 million people of pensionable age will be living in the UK, with twice as many females as males over the age of 85. The UK population of older people is not a homogenous group. It will also be more ethnically and culturally diverse as second and third generations of immigrants reach older age.

In discussing the needs of older people and their use of services, the increase in impairment and disability with age must also be considered. The 1988 Office of Population Census and Surveys (OPCS) survey, the first of its kind in the UK to look at this from a functional rather than a medical perspective, estimated that 6.2 million of the adult population of Great Britain, of which 4.2 million were aged 60 or more, had a level of ‘disability’ above that laid down by criteria for the survey. The overall rate of ‘disability’ increased with age, accelerating after the age of 50 years. ‘Disability’ rose very steeply over the age of 70, with almost 70% of ‘disabled’ adults aged over 60, and almost 50% aged 70 or over. The most severely ‘disabled’ lived in residential or institutional care. Mobility was the most frequently reported functional problem with hearing impairment and the inability to manage personal care affecting more than a third of ‘disabled’ people. In the 60–74 age group, approximately 20% were estimated to have impaired mobility, rising to 46% in those aged over 75.

More recent reports confirm that long-term illness limits the lifestyle of over a third of the population aged 65 to 74, and almost half the population over 75, particularly:

• Loss of mobility increases with age

• The greatest decline in mobility is in people aged 75 and over

• Sensory impairments become more common as people age

• Around 80% of people over 60 have a visual impairment

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• 75% of people over 60 have a hearing impairment

• 22% have both visual and hearing impairment.

The numbers with cognitive impairment will increase because the chances of developing dementia rise sharply with age. The Alzheimer’s Society estimates that there are currently 700,000 people in the UK with dementia. The majority are aged 65 years or older. However progress in the understanding of conditions such Alzheimer’s disease may lead to developments in its prevention and treatment so predictions must be viewed with caution.

The National Service Framework for Older People distinguishes between people who are functionally independent and those who are functionally dependent or frail regardless of age.

Effective mouth care requires motor skill and manual dexterity. Older people who are active and independent should have little difficulty maintaining oral health.

However functional impairment will pose limitations on the management of personal oral hygiene and is likely to severely restrict access to dental care and information on services. The Government’s report, Access to NHS Dentistry confirmed the fact that older people and people with dementia experience particular problems accessing NHS dental care. Older people in residential care do not receive uniformly high standards of oral health care and this is confirmed by a number of studies. Guidelines to address these issues provide a framework for developing standards to improve oral health in residential care settings.

Oral effects of ageing Tooth loss is not an inevitable consequence of ageing, although there are changes in oral tissues and surrounding structures associated with the ageing process. The degree of change depends on a variety of individual factors:

• Genetic influences

• Lifestyle • Habits

• Experience of disease

• Nutrition.

Teeth Tooth structure undergoes changes with age. Attrition, loss of tooth substance through wear is related to diet, habits such as bruxism and to the extra load

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that is placed upon the remaining teeth when some teeth have been lost.

Attrition of the biting surfaces may lead to loss of facial height, although this is sometimes compensated for by an extra deposit of cement around the roots (hypercementosis).

Enamel may also be lost due to erosion or abrasion as a result of excessive or incorrect brushing techniques. Abrasion is most pronounced at the cervical surface (neck) of the tooth where the gum may have receded. Enamel also appears to darken with age due to the formation of additional layers of dentine within the tooth structure. The overall effect is that teeth become less sensitive to external stimuli.

Decay occurs more frequently in exposed root surfaces (root caries). It is thought to be due to gingival recession (receding gums) exposing dentine which covers the root surface. Dentine is less resistant to caries than enamel, and together with poor oral hygiene and a soft diet create ideal conditions for root caries, the characteristic pattern of dental caries in older people.

Changes in structure with age make teeth more brittle. This increases the risk of fracture, particularly during extraction. Deposits of cementum around the roots may create complications for extractions and these are important considerations in planning dental treatment.

Bone Age changes in bone affect the maxilla, mandible and other facial bones. Increased porosity and bone resorption follow tooth loss which leads to a greater potential for fracture. The cortical (surface) bone becomes thinner and in many older people, loss of bony ridges to support and stabilise a denture leads to difficulty in wearing dentures, particularly in the lower jaw.

Bone previously affected by periodontal disease is resorbed more quickly. Loss of function and wearing dentures that are entirely supported by soft tissue rather than by teeth can also contribute to increased bone loss. The changes described predispose to fracture and delayed healing, which have implications for dental treatment, leading to greater difficulty in construction of stable dentures.

Oral tissues Mucous membranes generally atrophy with age. The rate at which this occurs in the mouth depends on diet, habits, denture wear and oral hygiene. The epithelium covering the cheeks and lips tends to become more keratinised, while the palate becomes less keratinised. Thinner oral mucosa is more easily damaged and penetrated by food substances and medication which may give rise to an itching or burning sensation.

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Saliva and salivary glands There is a considerable body of evidence to demonstrate the impact of salivary flow on oral health; with a lower flow rate the composition of saliva appears to have fewer protective properties. Changes in structure of the salivary glands are recorded and medication and salivary gland disease may reduce salivary flow, leading to dry mouth (xerostomia). Age and medication are significant risk factors for xerostomia but medication is a better predictor of risk status than age. The onset of xerostomia is associated with an increase in other oral symptoms, and problems with eating, communication and social interaction. Thinner oral mucosa and a reduction in saliva can lead to serious problems that have an impact on an individual’s quality of life.

Oral status In 1968, 63% of the adult UK population were dentate, whereas the 2009 Adult Dental Health Survey reported that 92% of all adults had some natural teeth. If the trend continues it is predicted that by 2028, the percentage with some natural teeth will rise to 96%. A small but varied group of people will continue to become edentulous (no natural teeth). Many older people are edentulous but the numbers are gradually declining; this is notable among younger age groups who are themselves approaching retirement age.

If the trend continues, future generations of older people will be more likely to retain some natural teeth. Many of the ‘young-old’ who retain their natural teeth have more positive attitudes to oral health and it is likely that their expectations of dental health will be greater. In planning dental services for future generations of an ageing population, it is anticipated that fewer complete dentures will be needed, but more partial dentures, fillings, crowns, and treatment for periodontal disease.

Most surveys of oral health in older people demonstrate a high need for treatment.

Surveys carried out in residential or sheltered accommodation, on patients in hospital continuing care and on specific community populations of frail or functionally dependent older people produce fairly consistent results that treatment needs include:

• Lack of dentures

• Loose dentures

• Ill fitting dentures

• Denture related pathology

• Improved standards of oral hygiene.

• Ulcers 98

• Dental caries

• Periodontal disease

• Extractions.

Amongst the frail or functionally dependent, it is general agreed that poor standards of oral hygiene and lack of access to professional oral health care contribute to high level of need. This is cause for serious concern as under-reporting of oral problems is common in older people.

Research paints a depressing picture of the outcome of poor standards of oral health care in residential accommodation. In a sample of 412 residents in 22 nursing homes:

• Over 70% had not seen a dentist in the previous 5 years

• 22% experienced some form of oral pain or discomfort requiring treatment, yet

a dental examination had not been arranged

• 82% of denture wearers were unable to clean their dentures

• 33% had denture related pathology generally associated with poor denture

hygiene and night denture wear

• 95% of dentures were considered to be un-hygienic

• 75% of dentate were unable to brush their teeth, yet none received regular

assistance

• Very high levels of plaque deposits and moderate gingivitis were recorded in

the dentate

• 63% had root caries and 82% had deposits of calculus.

These problems are fairly consistent with those reported in other surveys.

Most residents required help with oral health care but many did not receive it. Levels of plaque and associated disease were high because staff did not deliver effective oral health care appropriate to residents’ needs and this in an environment where complete personal care of residents is assumed and expected.

Dental services that are tailored to the needs and wants of the individual must address these barriers. Identifying frail and dependent individuals can only be achieved by an outreach approach in liaison with health, social care and voluntary agencies who provide care and support for older people. By providing information on the oral health needs of older people, the availability of appropriate dental services and the principles and practice of good oral care, primary health care professionals will be better equipped to identify problems, provide appropriate oral care and access dental services.

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