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Chapter 44 - Oral Health

from Section III - Care of the Elderly by Organ System

Published online by Cambridge University Press:  30 June 2022

By
Sarah G. Lowman ,
Jonathan M. Reside  and
Ingeborg J. De Kok
Edited by
Jan Busby-Whitehead ,
Samuel C. Durso ,
Christine Arenson ,
Rebecca Elon ,
Mary H. Palmer  and
William Reichel
Jan Busby-Whitehead
Affiliation:
University of North Carolina, Chapel Hill
Samuel C. Durso
Affiliation:
The Johns Hopkins University, Maryland
Christine Arenson
Affiliation:
Thomas Jefferson University, Philadelphia
Rebecca Elon
Affiliation:
The Johns Hopkins University School of Medicine
Mary H. Palmer
Affiliation:
University of North Carolina, Chapel Hill
William Reichel
Affiliation:
Georgetown University Medical Center
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Summary

This chapter explores oral health as a component of overall health and well-being in older adults. The primary focus is on older adults who live independently and in long-term care settings. Common oral diseases among this population include dental caries, periodontal disease, and oropharyngeal cancers. Discussion of each includes common signs and symptoms, etiology of disease, established risk factors, health disparities, and approaches to disease prevention and treatment. Oral hygiene is particularly important for oral disease prevention, but may present unique challenges for older adults. Oral hygiene strategies are discussed in the context of geriatric care. In addition, the authors present a framework for integrating oral health into primary care practice to improve outcomes for older adults.

Keywords

oral hygienedental cariesperiodontitisoropharyngeal cancerdenturesinterprofessional collaboration
Type
Chapter
Information
Reichel's Care of the Elderly
Clinical Aspects of Aging
 , pp. 548 - 557
Publisher: Cambridge University Press
Print publication year: 2022

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References

Genco, RJ, Sanz, M. Clinical and public health implications of periodontal and systemic diseases: An overview. Periodontol 2000. 2020 (Jun.);83(1):7–13.Google Scholar
Ortíz-Barrios, LB, Granados-García, V, Cruz-Hervert, P, Moreno-Tamayo, K, Heredia-Ponce, E, Sánchez-García, S. The impact of poor oral health on the oral health-related quality of life (OHRQoL) in older adults: The oral health status through a latent class analysis. BMC Oral Health. 2019 (Jul. 10);19(1):141.CrossRefGoogle ScholarPubMed
Kiesswetter, E, Hengeveld, LM, Keijser, BJ, Volkert, D, Visser, M. Oral health determinants of incident malnutrition in community-dwelling older adults. J Dent. 2019 (Jun.);85:73–80. doi: 10.1016/j.jdent.2019.05.017.Google Scholar
Berg, R, Berkey, DB, Tang, JM, Baine, C, Altman, DS. Oral health status of older adults in Arizona: Results from the Arizona Elder Study. Spec Care Dentist. 2000 (Nov.–Dec.;20(6):226–233. doi: 10.1111/j.1754-4505.2000.tb01155.x.Google Scholar
Han, SH, Wu, B, Burr, JA. Edentulism and trajectories of cognitive functioning among older adults: The role of dental care service utilization. J Aging Health. 2019; (May 26):898264319851654. doi: 10.1177/0898264319851654.Google Scholar
Vorvick, LJ. Tooth anatomy: MedlinePlus medical encyclopedia image. Bethesda, MD: US National Library of Medicine, National Institutes of Health, US Department of Health and Human Services, 2020. https://medlineplus.gov/ency/imagepages/1121.htm.Google Scholar
Featherstone, JD. The continuum of dental caries: Evidence for a dynamic disease process. J Dent Res. 2004; 83: Spec No. C:C39–42.Google Scholar
Dental caries (tooth decay) in seniors (age 65 and over). Bethesda, MD: National Institute of Dental and Craniofacial Research, National Institutes of Health, US Department of Health and Human Services, 2018. www.nidcr.nih.gov/research/data-statistics/dental-caries/seniors.Google Scholar
Stephens, R, White, BA. Oral health status of adults in North Carolina assisted living facilities. J Public Health Dent. 2019 (Sep.);79(3):198–206. doi: 10.1111/jphd.12310.Google Scholar
Dye, BA, Tan, S, Smith, V, Lewis, BG, Barker, LK, Thornton-Evans, G, Eke, PI, Beltrán-Aguilar, ED, Horowitz, AM, Li, CH. Trends in oral health status: United States, 1988–1994 and 1999–2004. Vital Health Stat. 2007 (Apr.); 248:1–92.Google Scholar
Hayes, M, Da Mata, C, Cole, M, McKenna, G, Burke, F, Allen, PF. Risk indicators associated with root caries in independently living older adults. J Dent. 2016 (Aug.);51:8–14. doi: 10.1016/j.jdent.2016.05.006.CrossRefGoogle ScholarPubMed
Dye, BA, Li, X, Thorton-Evans, G. Oral health disparities as determined by selected healthy people 2020 oral health objectives for the United States, 2009–2010. NCHS Data Brief. 2012 (Aug.); (104):1–8.Google Scholar
Selwitz, RH, Ismail, AI, Pitts, NB. Dental caries. Lancet. 2007 (Jan. 6);369(9555):51–59.CrossRefGoogle ScholarPubMed
Freire, M, Moustafa, A, Harkins, DM, Torralba, MG, Zhang, Y, Leong, P, Saffery, R, Bockmann, M, Kuelbs, C, Hughes, T, Craig, JM, Nelson, KE. Longitudinal study of oral microbiome variation in twins. Sci Rep. 2020 (May 14); 10(1):7954.Google Scholar
Loesche, WJ. Role of Streptococcus mutans in human dental decay. Microbiol Rev. 1986 (Dec.);50(4):353–380.CrossRefGoogle ScholarPubMed
Conrads, G, About, I. Pathophysiology of dental caries. Monogr Oral Sci. 2018; 27:1–10. doi: 10.1159/000487826.Google Scholar
Lindh, L, Aroonsang, W, Sotres, J, Arnebrant, T. Saliva pellicles. In: Ligtenberg, AJ, Veerman, EC, eds. Saliva: Secretion and Functions. Basel: Karger Medical and Scientific Publishers, 2014, pp. 30‐87.Google Scholar
Liu, B, Dion, MR, Jurasic, MM, Gibson, G, Jones, JA. Xerostomia and salivary hypofunction in vulnerable elders: Prevalence and etiology. Oral Surg Oral Med Oral Pathol Oral Radiol. 2012 (Jul.);114(1):52–60.Google Scholar
Sreebny, LM. Saliva in health and disease: An appraisal and update. Int Dent J. 2000 (Jun.); 50(3):140–161. doi:10.1111/j.1875-595x.2000.tb00554.x.Google Scholar
Murray Thomson, W, Chalmers, JM, John Spencer, A, Slade, GD, Carter, KD. A longitudinal study of medication exposure and xerostomia among older people. Gerodontology. 2006 (Dec.); 23(4):205–213.Google Scholar
Nederfors, T, Isaksson, R, Mörnstad, H, Dahlöf, C. Prevalence of perceived symptoms of dry mouth in an adult Swedish population: Relation to age, sex and pharmacotherapy. Community Dent Oral Epidemiol. 1997; 25(3):211–216.Google Scholar
Pereira, GF, Bulik, CM, Weaver, MA, Holland, WC, Platts-Mills, TF. Malnutrition among cognitively intact, noncritically ill older adults in the emergency department. Ann Emerg Med. 2015 (Jan.); 65(1):85–91. doi: 10.1016/j.annemergmed.2014.07.018.Google Scholar
Bibby, BG. The cariogenicity of snack foods and confections. J Am Dent Assoc. 1975 (Jan.);90(1):121–132.Google Scholar
Tanner, T, Harju, L, Päkkilä, J, Patinen, P, Tjäderhane, L, Anttonen, V. Consumption of snacks and dental caries among Finnish young men: A cross-sectional epidemiological study. Odontology. 2020 (Jul.);108(3):486–492. doi: 10.1007/s10266-019-00473-z.CrossRefGoogle Scholar
Tonetti, MS, Greenwell, H, Kornman, KS. Staging and grading of periodontitis: Framework and proposal of a new classification and case definition. J Clin Periodontol. 2018 (Jun.); 45(Suppl. 20):S149-S161. doi: 10.1111/jcpe.12945. Erratum in: J Clin Periodontol. 2019 (Jul.); 46(7):787.Google Scholar
Beydoun, MA, Beydoun, HA, Hossain, S, El-Hajj, ZW, Weiss, J, Zonderman, AB. Clinical and bacterial markers of periodontitis and their association with incident all-cause and Alzheimer’s disease dementia in a large national survey. J Alzheimers Dis. 2020; 75(1):157–172.Google Scholar
Panezai, J, Ali, A, Ghaffar, A, Benchimol, D, Altamash, M, Klinge, B, Engström, PE, Larsson, A. Upregulation of circulating inflammatory biomarkers under the influence of periodontal disease in rheumatoid arthritis patients. Cytokine. 2020; 131:155117. doi: 10.1016/j.cyto.2020.155117.Google Scholar
Parida, S, Sharma, D. Microbial alterations and risk factors of breast cancer: Connections and mechanistic insights. Cells. 2020 (Apr. 28);9(5):1091.Google Scholar
Eke, PI, Thornton-Evans, GO, Wei, L, Borgnakke, WS, Dye, BA, Genco, RJ. Periodontitis in US adults: National health and nutrition examination survey 2009–2014. J Am Dent Assoc. 2018 (Jul.); 149(7):576–588.Google Scholar
Papapanou, PN, Sanz, M, Buduneli, N, et al. Periodontitis: Consensus report of workgroup 2 of the 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions. J Clin Periodontol. 2018 (Jun.); 45(Suppl. 20):S162–S170.Google Scholar
Sanz, M, Beighton, D, Curtis, MA, et al. Role of microbial biofilms in the maintenance of oral health and in the development of dental caries and periodontal diseases. Consensus report of group 1 of the Joint EFP/ORCA workshop on the boundaries between caries and periodontal disease. J Clin Periodontol. 2017 (Mar.);44(Suppl. 18):S5–S11.Google Scholar
Genco, RJ, Borgnakke, WS. Diabetes as a potential risk for periodontitis: Association studies. Periodontol 2000. 2020 (Jun.);83(1):40–45.Google Scholar
Genco, RJ, Graziani, F, Hasturk, H. Effects of periodontal disease on glycemic control, complications, and incidence of diabetes mellitus. Periodontol 2000. 2020 (Jun.);83(1):59–65.CrossRefGoogle ScholarPubMed
Nociti, FH Jr, Casati, MZ, Duarte, PM. Current perspective of the impact of smoking on the progression and treatment of periodontitis. Periodontol 2000. 2015 (Feb.); 67(1):187–210.Google Scholar
Ellington, TD, Henley, SJ, Senkomago, V, O’Neil, ME, Wilson, RJ, Singh, S, Thomas, CC, Wu, M, Richardson, LC. Trends in incidence of cancers of the oral cavity and pharynx – United States 2007–2016. MMWR Morb Mortal Wkly Rep. 2020 (Apr. 17); 69(15):433–438.Google Scholar
Van Dyne, EA, Henley, SJ, Saraiya, M, Thomas, CC, Markowitz, LE, Benard, VB. Trends in human papillomavirus-associated cancers – United States, 1999–2015. MMWR Morb Mortal Wkly Rep. 2018 (Aug. 24); 67(33):918–924.Google Scholar
Ward, MJ, Mellows, T, Harris, S, Webb, A, Patel, NN, Cox, HJ, Piper, K, Ottensmeier, CH, Thomas, GJ, King, EV. Staging and treatment of oropharyngeal cancer in the human papillomavirus era. Head Neck. 2015 (Jul.); 37(7):1002–1013. doi: 10.1002/hed.23697.CrossRefGoogle ScholarPubMed
Høxbroe Michaelsen, S, Grønhøj, C, Høxbroe Michaelsen, J, Friborg, J, von Buchwald, C. Quality of life in survivors of oropharyngeal cancer: A systematic review and meta-analysis of 1366 patients. Eur J Cancer. 2017 (Jun.); 78:91–102. doi: 10.1016/j.ejca.2017.03.006.CrossRefGoogle Scholar
Siegel, RL, Miller, KD, Jemal, A. Cancer statistics, 2020. CA Cancer J Clin. 2020 (Jan.); 70(1):7–30. doi: 10.3322/caac.21590.Google Scholar
Windon, MJ, D’Souza, G, Rettig, EM, et al. Increasing prevalence of human papillomavirus-positive oropharyngeal cancers among older adults. Cancer. 2018 (Jul. 15); 124(14):2993–2999. doi: 10.1002/cncr.31385.Google Scholar
DeSantis, CE, Miller, KD, Goding Sauer, A, Jemal, A, Siegel, RL. Cancer statistics for African Americans, 2019. CA Cancer J Clin. 2019 (May); 69(3):211–233. doi: 10.3322/caac.21555.Google Scholar
DeSantis, C, Naishadham, D, Jemal, A. Cancer statistics for African Americans, 2013. CA Cancer J Clin. 2013 (May); 63(3):151–166. doi: 10.3322/caac.21173.CrossRefGoogle ScholarPubMed
Osazuwa-Peters, N, Massa, ST, Christopher, KM, Walker, RJ, Varvares, MA. Race and sex disparities in long-term survival of oral and oropharyngeal cancer in the United States. J Cancer Res Clin Oncol. 2016 (Feb.); 142(2):521–528. doi: 10.1007/s00432-015-2061-8.Google Scholar
Settle, K, Posner, MR, Schumaker, LM, et al. Racial survival disparity in head and neck cancer results from low prevalence of human papillomavirus infection in black oropharyngeal cancer patients. Cancer Prev Res (Phila). 2009 (Sep.); 2(9):776–781. doi: 10.1158/1940-6207.CAPR-09-0149.Google Scholar
Gandini, S, Botteri, E, Iodice, S, Boniol, M, Lowenfels, AB, Maisonneuve, P, Boyle, P. Tobacco smoking and cancer: A meta-analysis. Int J Cancer. 2008 (Jan. 1); 122(1):155–164.Google Scholar
Slaughter, DP, Southwick, HW, Smejkal, W. Field cancerization in oral stratified squamous epithelium: Clinical implications of multicentric origin. Cancer. 1953 (Sep.); 6(5):963–968.Google Scholar
Russo, D, Merolla, F, Varricchio, S, Salzano, G, Zarrilli, G, Mascolo, M, Strazzullo, V, Di Crescenzo, RM, Celetti, A, Ilardi, G. Epigenetics of oral and oropharyngeal cancers. Biomed Rep. 2018 (Oct.); 9(4):275–283. doi: 10.3892/br.2018.1136. Erratum in: Biomed Rep. 2020 (May); 12(5):290.Google Scholar
Piña, AR, Fonseca, FP, Pontes, FS, Pontes, HA, Pires, FR, Mosqueda-Taylor, A, Aguirre-Urizar, JM, de Almeida, OP. Benign epithelial oral lesions: Association with human papillomavirus. Med Oral Patol Oral Cir Bucal. 2019 (May 1); 24(3):e290–e295.Google Scholar
Phillips, KE, Hummel, J. Oral health in primary care: A framework for action. JDR Clin Trans Res. 2016 (Apr. 1); 1:6–9.Google Scholar
McKernan, SC, Kuthy, RA, Reynolds, JC, Tuggle, L, García, DT. Medical-Dental Integration in Public Health Settings: An Environmental Scan. Iowa City: University of Iowa Public Policy Center, 2018. https://ppc.uiowa.edu/sites/default/files/ced_environmental_scan.pdf.Google Scholar
Griffin, SO, Regnier, E, Griffin, PM, Huntley, V. Effectiveness of fluoride in preventing caries in adults. J Dent Res. 2007 (May); 86(5):410–415.Google Scholar
From the Centers for Disease Control and Prevention. Achievements in public health, 1900–1999: Fluoridation of drinking water to prevent dental caries. JAMA. 2000 (Mar. 8); 283(10):1283–1286.Google Scholar
Walsh, T, Worthington, HV, Glenny, AM, Marinho, VC, Jeroncic, A. Fluoride toothpastes of different concentrations for preventing dental caries. Cochrane Database Syst Rev. 2019 (Mar. 4); 3(3):CD007868.Google Scholar
Urquhart, O, Tampi, MP, Pilcher, L, et al. Nonrestorative treatments for caries: Systematic review and network meta-analysis. J Dent Res. 2019 (Jan.); 98(1):14–26. doi: 10.1177/0022034518800014.Google Scholar
Zhang, J, Sardana, D, Li, KY, Leung, KCM, Lo, ECM. Topical fluoride to prevent root caries: Systematic review with network meta-analysis. J Dent Res. 2020 (May); 99(5):506–513. doi: 10.1177/0022034520906384.Google Scholar
Yaacob, M, Worthington, HV, Deacon, SA, Deery, C, Walmsley, AD, Robinson, PG, Glenny, AM. Powered versus manual toothbrushing for oral health. Cochrane Database Syst Rev. 2014 (Jun. 17); 2014(6):CD002281.Google Scholar
Marchesan, JT, Byrd, KM, Moss, K, Preisser, JS, Morelli, T, Zandona, AF, Jiao, Y, Beck, J. Flossing is associated with improved oral health in older adults. J Dent Res. 2020 (Apr. 22):22034520916151. doi: 10.1177/0022034520916151.Google Scholar
Felder, R, James, K, Brown, C, Lemon, S, Reveal, M. Dexterity testing as a predictor of oral care ability. J Am Geriatr Soc. 1994 (Oct.); 42(10):1081–1086.Google Scholar
Barouch, K, Al Asaad, N, Alhareky, M. Clinical relevance of dexterity in oral hygiene. Br Dent J. 2019 (Mar.); 226(5):354–357.Google Scholar
Padilha, DM, Hugo, FN, Hilgert, JB, Dal Moro, RG. Hand function and oral hygiene in older institutionalized Brazilians. J Am Geriatr Soc. 2007 (Sep.); 55(9):1333–1338.Google Scholar
Naorungroj, S, Slade, GD, Beck, JD, Mosley, TH, Gottesman, RF, Alonso, A, Heiss, G. Cognitive decline and oral health in middle-aged adults in the ARIC study. J Dent Res. 2013 (Sep.); 92(9):795–801. doi: 10.1177/0022034513497960.Google Scholar
Naorungroj, S, Schoenbach, VJ, Wruck, L, Mosley, TH, Gottesman, RF, Alonso, A, Heiss, G, Beck, J, Slade, GD. Tooth loss, periodontal disease, and cognitive decline in the Atherosclerosis Risk in Communities (ARIC) study. Community Dent Oral Epidemiol. 2015 (Feb.); 43(1):47–57. doi: 10.1111/cdoe.12128.Google Scholar
Avlund, K, Holm-Pedersen, P, Morse, DE, Viitanen, M, Winblad, B. Tooth loss and caries prevalence in very old Swedish people: The relationship to cognitive function and functional ability. Gerodontology. 2004 (Mar.); 21(1):17–26.Google Scholar
Ellefsen, B, Holm-Pedersen, P, Morse, DE, Schroll, M, Andersen, BB, Waldemar, G. Assessing caries increments in elderly patients with and without dementia: A one-year follow-up study. J Am Dent Assoc. 2009 (Nov.); 140(11):1392–400.Google Scholar
Delwel, S, Binnekade, TT, Perez, RSGM, Hertogh, CMPM, Scherder, EJA, Lobbezoo, F. Oral hygiene and oral health in older people with dementia: A comprehensive review with focus on oral soft tissues. Clin Oral Investig. 2018 (Jan.); 22(1):93–108. doi: 10.1007/s00784-017-2264-2.Google Scholar
Wu, B, Fillenbaum, GG, Plassman, BL, Guo, L. Association between oral health and cognitive status: A systematic review. J Am Geriatr Soc. 2016 (Apr.); 64(4):739–51. doi: 10.1111/jgs.14036. Erratum in: J Am Geriatr Soc. 2016 (Aug.); 64(8):1752.Google Scholar
Coleman, P, Watson, NM. Oral care provided by certified nursing assistants in nursing homes. J Am Geriatr Soc. 2006 (Jan.); 54(1):138–143.Google Scholar
Hoben, M, Clarke, A, Huynh, KT, Kobagi, N, Kent, A, Hu, H, Pereira, RAC, Xiong, T, Yu, K, Xiang, H, Yoon, MN. Barriers and facilitators in providing oral care to nursing home residents, from the perspective of care aides: A systematic review and meta-analysis. Int J Nurs Stud. 2017 (Aug.); 73:34–51. doi: 10.1016/j.ijnurstu.2017.05.003.Google Scholar
Zimmerman, S, Sloane, PD, Ward, K, Wretman, CJ, Stearns, SC, Poole, P, Preisser, JS. Effectiveness of a mouth care program provided by nursing home staff vs standard care on reducing pneumonia incidence: A cluster randomized trial. JAMA Netw Open. 2020 (Jun. 1); 3(6):e204321.Google Scholar
Albrecht, M, Kupfer, R, Reissmann, DR, Mühlhauser, I, Köpke, S. Oral health educational interventions for nursing home staff and residents. Cochrane Database Syst Rev. 2016 (Sep. 30); 9(9):CD010535.Google Scholar
Mann, J, Doshi, M. An investigation into denture loss in hospitals in Kent, Surrey and Sussex. Br Dent J. 2017 (Aug. 25). https://mouthcarematters.hee.nhs.uk/wp-content/uploads/2017/02/sj.bdj_.2017.728-Dentures.pdf. doi: 10.1038/sj.bdj.2017.728.Google Scholar
van Hoof, J, Douven, B, Janssen, BM, Bosems, WPH, Oude Weernink, CE, Vossen, MB. Losing items in the psychogeriatric nursing home: The perspective of residents and their informal caregivers. Gerontol Geriatr Med. 2016 (Sep. 21); 2:2333721416669895.Google Scholar
Willink, A, Schoen, C, Davis, K. Dental care and medicare beneficiaries: Access gaps, cost burdens, and policy options. Health Aff (Millwood). 2016 (Dec. 1); 35(12):2241–2248. doi: 10.1377/hlthaff.2016.0829. Erratum in: Health Aff (Millwood). 2017 (Feb. 1); 36(2):384.Google Scholar
Mertz, E, Wides, C. Evolving Delivery Models for Dental Care Services in Long-Term Care Settings: 4 State Case Studies. Rensselaer, NY: Oral Health Workforce Research Center, Center for Health Workforce Studies, School of Public Health, SUNY Albany, 2016. www.chwsny.org/wp-content/uploads/2016/06/OHWRC_Long_Term_Care_2016.pdf.Google Scholar
Fitzgerald, R, Gallagher, J. Oral health in end-of-life patients: A rapid review. Spec Care Dentist. 2018 (Sep.); 38(5):291–298. doi: 10.1111/scd.12316.Google Scholar
Chen, X, Chen, H, Douglas, C, Preisser, JS, Shuman, SK. Dental treatment intensity in frail older adults in the last year of life. J Am Dent Assoc. 2013 (Nov.); 144(11):1234–1242.Google Scholar
Soileau, K, Elster, N. The hospice patient’s right to oral care: Making time for the mouth. J Palliat Care. 2018 (Apr.); 33(2):65–69. doi: 10.1177/0825859718763283.Google Scholar
Caries Risk Assessment Form (Age >6). Chicago, IL: American Dental Association, 2011. www.ada.org/~/media/ADA/Science%20and%20Research/Files/topic_caries_over6.ashx.6).+Chicago,+IL:+American+Dental+Association,+2011.+www.ada.org/~/media/ADA/Science%20and%20Research/Files/topic_caries_over6.ashx.>Google Scholar

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