Older adults: demographics and need for quality care

The elderly are becoming important consumers of dental care because of several factors. These include (1) decreasing caries rates among children and young adults, (2) increasing numbers of older adults in the population, (3) increasing retention of natural teeth by the elderly, (4) increasing prevalence of coronal and root surface caries associated with advanced age, (5) large unmet need for prosthodontic care projected for coming years, and (6) significant disposable income available to many older persons. This article reviews the importance to dentists of physiologic and pathologic changes associated with aging and the need for developed diagnostic and clinical skills in providing dental care.     

Twenty-four month coronal caries incidence: the role of dental care and race

OBJECTIVES: To describe for a diverse sample of dentate middle-aged and older adults: (1) the 24-month incidence of coronal caries, and (2) its association with a broad range of clinical, behavioral, financial, attitudinal, and sociodemographic factors. METHODS: The Florida Dental Care Study is a prospective observational longitudinal cohort study of 873 persons who at baseline had at least 1 tooth and were 45 years or older. In-person interviews and clinical examinations were conducted at baseline and 24 months, with 6-monthly telephone interviews between those times. A multinomial logistic regression was done to predict whether a participant was in one of four mutually exclusive groups at the 24-month examination (new decay only [NDO]; new filling(s) only [NFO]; both new decay and filling(s) [BOTH]; or neither [NONE]). RESULTS: Only 33% of the 24-month participants were in the NONE group. There was no significant difference in caries incidence between regular attenders and problem-oriented attenders, regardless of whether teeth crowned at baseline, incident crowns, or incident root fragments were excluded. However, once differences in incident tooth loss and baseline clinical, behavioral, financial, and attitudinal differences were taken into account, regular attenders did appear to benefit by developing fewer coronal lesions and fewer dental symptoms than problem-oriented attenders. Baseline carious surfaces, filled surfaces, number of teeth, and bulk restoration fractures predicted caries incidence, but baseline cusp fractures did not. Persons with negative dental attitudes were more likely to be in the NDO and BOTH groups, and negative attitude toward brushing and flossing (but not their frequency) also predicted caries incidence. CONCLUSION: Certain baseline clinical conditions, approach to dental care, ability to pay for dental care, dental attitudes, race, and age group were predictive of coronal caries incidence, and regular attenders appeared to benefit from regular attendance.     

Ten-year incidence of tooth loss and dental caries in elderly Swedish individuals

There has been a significant reduction in edentulism and the elderly retain more teeth into old age. The 10-year incidence of tooth loss, coronal and root caries was studied in a random sample of inhabitants of G?teborg, who were 55, 65 and 75 years old at baseline. Of the 208 persons examined at baseline, 102 (49%) participated in the follow-up examination: 56, 37 and 9, respectively, in the different age groups of 65, 75 and 85 years. In addition, for the purpose of time-trend comparisons, a new random sample of 98 individuals aged 55 years was examined. The mean numbers of remaining teeth were 24, 23, 17 and 14, respectively, in the age groups of 55, 65, 75 and 85. The corresponding mean numbers at baseline were 23, 19 and 17, respectively, in those subjects who were then 55, 65 and 75 years old. Forty-eight percent had lost no teeth during the 10-year period, while 13% had lost more than 2 teeth. The major reason for tooth extraction was dental caries and it was found in 60% of all cases. The incidence of coronal caries decreased, while that of root caries increased with age (p < 0.01). Comparing the same age groups, the frequency of root caries had decreased during the 10-year period. It could be concluded from this study that elderly people were determined to retain their teeth for as long as possible, but dental caries may be a problem among the very old.     

Models for coronal caries and root fragments in an elderly population.

A random sample of 809 dentate, home-dwelling people 65 years of age or older participated in a study to determine the prevalence of dental diseases in the elderly. Part of the study investigated the determinants of coronal caries and root fragments in these older adults. Using a wide array of potentially explanatory variables available, logistic regression models were developed to identify relationships between these variables and coronal caries and root fragments. The variables with the most explanatory power in the coronal caries model were the presence of decayed root surfaces, lower salivary flow rate, lack of regular dental care and an interaction variable including race and a perception of financial well-being. When a subsequent model was created that did not include decayed root surfaces or root fragments as potential explanatory variables, an additional variable relating to self-perception of mouth appearance emerged. The strongest variables in the model for root fragments were episodic (vs. regular) dental visits, presence of root caries, lack of replacement for lost teeth, high levels of Streptococcus mutans and number of teeth present in the mouth.     

Tooth loss as related to dental caries and periodontal breakdown in adult Tanzanians

A total of 170 adults aged 30-69 yr from the Zanzibar and Pemba Islands (Tanzania) were examined for tooth loss, dental caries and loss of periodontal attachment. The cause of tooth loss was recorded from information given by the examinee to a Kiswahili-English interpreter. Dental caries were recorded according to the depth of the lesion, i.e. involving enamel, dentin or pulp, respectively. Loss of attachment was measured as the distance in mm from the CEJ to the bottom of the pocket. The most severely affected surface determined the state of the tooth. The mean number of teeth present ranged from 29.5 in the youngest to 23.9 in the oldest age group. The mean number of teeth missing due to dental caries ranged between 2.1 and 7.0 teeth, and exceeded by far tooth loss due to periodontal breakdown which was only observed in the two oldest age groups. In all age groups the molars were the teeth most frequently missing and also the teeth most frequently affected by dental caries. Although a substantial number of the teeth in the older age groups demonstrated an extensive loss of attachment only a few teeth, mainly mandibular incisors, were lost due to periodontal breakdown within the age range examined.     

Incidence of tooth loss and dental caries in 60-, 70- and 80-year-old Swedish individuals

Abstract The retention of natural teeth among the elderly is increasing and, in recent studies, dental caries has been identified as the main reason for teeth being extracted. The 5-year incidence of tooth loss and dental caries and the most crucial dental factors for tooth extraction were studied in a random sample of 60-. 70- and 80-year-old inhabitants of Gothenburg, Of the 208 persons examined at baseline, 148 (71%) participated in the follow-up examination: 69, 51 and 28 respectively in the different age groups. In all. 110 teeth had been extracted during the period in 40% of the participants. Only 9 persons had lost three or more teeth. The mean numbers of remaining teeth were 22, 18 and 15 respectively in the 60-, 70- and 80-year age groups and the mean numbers of teeth lost during the 5-year period increased with age from 0.4 in the 60-year-olds to 0.8 and 1.4 in the 70- and 80-year-olds (P<0.05). The major reason for tooth extraction was dental caries and it was found in 60% of all cases and at a higher rate of 77%i in the oldest age group. Fifty-one per cent had developed new coronal carious lesions and 61% had new root carious lesions, while 27% had not developed caries during the period. The mean 5-year increment in decayed and filled coronal surfaces increased with age from 2.3 in the 60-year-olds to 3.7 and 5.3 in the 70- and 80-year-olds (N.S.). The increment in decayed and filled root surfaces was higher in women than men, 3.4 compared with 1.8 (N.S.), which also increased with age from 1.4 in the 60-year-olds to 2.4 and 5.5 in the 70- and 80-year-olds (P<0.0001). It was concluded from this study that few teeth had been lost during the 5-year period but that dental caries still appeared to be a serious problem among some very elderly people.     

Risk factors for and the prevention of root caries in older adults

With the absolute and relative number of elderly people rising in most countries, it is essential that dental practitioners be knowledgeable about the normal changes and disease processes that occur in aging individuals. Especially prevalent in the aging population is root surface caries. Several variables may increase the risk of developing root surface caries. Among these are poor oral hygiene, microbial plaque, periodontal disease, gender (male), coronal caries, dietary habits, xerostomia, low socio-economic status, and infrequent dental visits. While each of these has an effect, plaque seems to have the greatest influence on the susceptibility of teeth to root decay. Improved oral hygiene and regular dental visits, combined with the use of fluoride, may continuously convert active root caries lesions to inactive. In fact, prophylactic programs are more effective in converting active to inactive rather than preventing the development of new lesions. The conscientious dental practitioner must identify his/her older patients at risk for developing root lesions and place a major emphasis on the prevention and treatment thereof.     

Consequences of Success: Do More Teeth Translate into More Disease and Utilization?

Objectives : Increased tooth retention coupled with increased numbers of older adults means that the actual number of teeth at risk to dental disease will increase sharply. Whether this increase in the number of teeth will translate into more disease and utilization in unknown. The purpose of this study was to test this "more teeth, therefore more dental disease" theory using cross-sectional data. Methods : In-home personal interview and oral examination data were obtained on a probability sample of elders aged 70 years and older living in the six New England states using the Medicare beneficiary list as a sampling frame. Data on dental utilization, number of teeth, dental caries, and periodontal disease were included in the current analysis. Results : Analysis of variance on subjects with 1–10 (Group 1), 11–24 (Group 2), and 25–32 (Group 3) teeth show that the extent of bleeding on probing, pocket depth, and loss of attachment all increase as numbers of teeth increase. Similarly, a greater number of restored coronal and root surfaces were found in Group 3 relative to the other two groups. Mean numbers of decayed and filled coronal surfaces were 8.4 in Group 1,33.0 in Group 2, and 50.3 in Group 3. In contrast, unrestored coronal and root surfaces were significantly higher in Group 1 (mean root DS=1.3) than Group 3 (mean root DS=0.3). Utilization patterns of those with successful aging dentitions (Group 3) show that they are visiting dentists more frequently than the compromised group (Group 1). Conclusion : These cross-sectional data obtained from a probability sample of New England elders show that subjects who retained higher numbers of teeth have more periodontal disease and dental caries experience, and visit the dentist more frequently.     

Dental caries experience in older people over time: what can the large cohort studies tell us?

BACKGROUND: Little was known of the natural history of dental caries among older adults until recently, but reports from a number of large cohort studies have now enabled better understanding of the nature and determinants of dental caries in older people. The aim of this review is to examine and compare findings from established population-based longitudinal studies of older adults in order to determine their preventive implications. METHODS: The dental literature was reviewed in order to identify reports on dental caries incidence from large, population-based dental longitudinal studies of older adults (age 50+) with at least 3 years of follow-up. RESULTS: Reports were identified from four studies (in Iowa, North Carolina, Ontario and South Australia) which met the criteria; four reports dealt with coronal caries, and five with root surface caries. When annualised, coronal and root surface caries increments were combined and compared with those reported for adolescents, the caries experience of older people over time (between 0.8 and 1.2 new surfaces affected per year) exceeded that reported from cohort studies of adolescents (between 0.4 and 1.2 surfaces per year). The only caries risk factor common to all four studies was the wearing of a partial denture (for root surface caries only). CONCLUSIONS: Older people are a caries-active group, experiencing new disease at a rate which is at least as great as that of adolescents. PRACTICE IMPLICATIONS: Dentate older people should be the target of intensive monitoring and preventive efforts at both the clinical practice and public health levels. There is no easily identifiable 'magic bullet' for preventing caries in that age group, but the use of evidence-based preventive interventions (such as fluoride) should suffice.     

Root caries in older people attending a general dental practice in East Sussex

With increasing numbers of older people retaining their natural dentitions, dentists are becoming increasingly aware of the problem of dental caries occurring on exposed root surfaces--root caries. This study reports the prevalence of root caries in a selected older population, living in the community and attending a general dental practice in Bexhill, East Sussex. A total of 146 non-institutionalised people, aged at least 55 years with at least 12 teeth, were examined. Most of the subjects (88.4%) had evidence of root caries, males and denture wearers having more lesions than females and non-denture wearers, respectively. Active coronal caries was present in only 11.6% of the subjects, whereas active (soft or leathery) root caries lesions were present in 31.5% of the subjects. The teeth and surfaces most commonly affected by root caries were found to be similar to those seen in previous epidemiological surveys. The majority of active root caries lesions were within 1 mm of the gingival margin, while inactive lesions tended to be greater than or equal to 1 mm from the gingival margin. Colour of root caries lesions was not diagnostic of caries activity. A more detailed method of recording root caries lesions is also described.     

Explorer probing of root caries lesions: an in vitro study

Probing with a dental explorer is the preferred method of root caries diagnoses. However, studies suggest that use of a dental explorer in coronal caries detection may damage tooth structure. This pilot study investigated the effect of probing on remineralization of root surface lesions in vitro .
Root-surface lesions were created on 10 extracted teeth by exposing them to a demineralizing solution for 21 days. One side of each lesion was then randomly selected and probed with an explorer, while the other side was not probed. The teeth then were placed in a remineralizing solution containing 10 parts per million (ppm) fluoride for 21 days.
Of the 9 teeth with usable sections, all showed frank evidence of defects on the probed halves. Sites of remineralization were seen in the non-probed halves and adjacent to the probed defects, but not within or at the base of these defects. These results suggest that probing of root surfaces may create defects that do not fully remineralize.     

Root surface caries prevalence and associated factors among adult patients in an acute care hospital.

There have been many studies reporting on the prevalence of root surface caries in elderly populations, but there is little consistency in these reports concerning the associated risk factors. In the present study, intraoral examinations were carried out on adult patients (age range 22 to 91 years, mean age 57.9) on the acute care wards of a teaching hospital. Of the 103 patients examined, 23.3% exhibited carious lesions on root surfaces, these lesions occurring more frequently in males than in females, and more frequently in the 60 years and older age groups. Forty-five per cent of all root lesions recorded were found on the buccal or facial root surfaces of teeth exhibiting root surface caries. Individuals exhibiting root surface caries had more surfaces with gingival recession and loss of attachment greater than or equal to 3mm, more retained roots, higher DMFT values, and less teeth. However, statistically significant relationships were not obtained between root surface caries and a) coronal caries, b) dental plaque, c) calculus, d) bleeding on probing, and e) probing depth greater than or equal to 4mm. Thirty-three strains of Actinomyces viscosus were isolated from plaque samples taken from root surface lesions compared to 21 strains isolated from intact root surfaces.     

Incidence of caries lesions in approximal surfaces: a radiographic study of a general adult Danish population

The aim was to describe the incidence of caries lesions in a randomly selected adult population, and to identify risk factors related to the incidence of caries lesions in approximal surfaces. In 1997, 616 adults participated in a study including a radiographic survey. In 2003 these individuals were contacted again and offered a second radiographic survey; 473 consented and attended this examination. In approximal surfaces, presence/absence of caries lesions and presence and type of coronal fillings were recorded. The incidence of caries lesions in surfaces with no caries lesions in 1997 was studied. Potential risk factors included information at three levels: (1) person, (2) tooth, and (3) surface. The analysis was carried out by multilevel logistic regression. For the analyses 23,701 approximal surfaces were eligible. In 23,243 approximal surfaces no caries lesions were detected in 1997, 17,007 of these were surfaces without fillings, and 6,236 were filled surfaces. In unfilled surfaces several factors affected the risk for development of a caries lesion: young age, high number of fillings, number of teeth and status of the adjacent surface. In filled surfaces few factors affected the incidence of caries lesions: status of the adjacent surface, smoking and distal surfaces. Differences in risk factor patterns for the incidence of caries lesions were found for unfilled and filled surfaces. The study emphasizes the importance of assessing factors related to the incidence of caries lesions in adults. Further it underlines the need to analyse the fate of filled surfaces separately, because once a surface has received a filling it needs continuous attendance.     

Pattern of dental caries in an adult rural population

A study was conducted amongst 1,131 randomly selected persons aged 15-65 years in a rural area of Kenya, having minimal access to dental care. A relatively low prevalence of frank cavitation was found in the 15- to 24-year-old cohort, but in the older age groups over 80% were so affected. Caries in the youngest cohort was characterized by a predominance of enamel lesions. At the age of 25-34 years, however, involvement of pulpal tissues and loss of teeth due to caries was more common, and this age group exhibited the largest number of dentinal lesions. The 35- to 44-year-old cohort exhibited fewer enamel and dentinal lesions, but more pulpally involved lesions and more extracted teeth. In the group aged 45-54 years, enamel and dentinal lesions were less common, and at the age of 55-65 years, such lesions were less common in comparison to their occurrence in younger cohorts. The 55- to 65-year cohort could generally be characterized as having larger numbers of root surface lesions, lesions involving the pulp, and extracted teeth. Root surface lesions were principally associated with age over 35 years. In all age groups caries exhibited a skewed distribution, most of the lesions occurring in a minority of individuals. This study demonstrates that caries activity continues throughout life and is not a phenomenon confined to any one period of life.     

Caries incidence and increments in Adelaide nursing home residents

The objective of The Adelaide Dental Study of Nursing Homes was to quantify coronal and root caries incidence and increments in residents of Adelaide nursing homes. A longitudinal design was used to conduct dental inspections, completed by calibrated dental examiners, for residents of 7 randomly selected nursing homes at both baseline and at one‐year follow‐up. The nursing home residents in this study were very functionally dependent, medically compromised, cognitively impaired and behaviorally difficult older adults. The coronal caries surface incidence was 64.4% and root caries surface incidence was 48.5%. There were 72.1% of residents who had coronal and/or root cartes increments between baseline and one‐year. The coronal and root caries increments in these residents were high (adjusted caries increment = 2.5 coronal and 1.0 root surfaces), and were many times greater than that reported from a longitudinal study of community‐dwelling older adults in Adelaide. Residents with eating and nutritional problems developed high levels of new caries. Both coronal and root caries incidence and increments were high in these nursing home residents over the one‐year follow‐up period.     

Relationship between root caries and coronal decay

The relationship between caries on root surfaces and untreated coronal lesions was analyzed. A representative sample of 5028 persons was examined, their mean ages being 47.3 years for men and 47.7 for women. Poor dental health on root surfaces was associated with poor dental health in the coronal areas of the teeth. Subjects with root caries had fewer teeth and fewer fillings, more retained roots and more teeth with untreated coronal decay than did people with no root caries. Compared with the subjects without untreated coronal decay, those with from one to three decayed coronal surfaces showed an odds ratio of 4.5 of having caries on root surfaces. This ratio was 10.1 for the subjects who had more than three decayed coronal surfaces. It was concluded that factors related to the occurrence of decay are of a similar type whether caries is situated on root surfaces or in the coronal areas of the teeth, and therefore the prevention of caries in both sites may be accomplished by similar means.     

Progression of dental caries and tooth loss between the third and fourth decades of life: a birth cohort study

The majority of what is known of the experience of dental caries among adults is from cross-sectional studies, and there are surprisingly few population-level longitudinal studies of dental caries among adults. Dental examinations were conducted at age 26 and again at age 32 among participants in a longstanding prospective study of a birth cohort born in Dunedin (New Zealand) in 1972/1973. Some 901 individuals (88.8%) were dentally examined at both ages. The mean number of remaining teeth and tooth surfaces fell between 26 and 32, reflecting ongoing tooth loss. The overall prevalence of caries rose from 94.9 to 96.8%, while there were greater increases in the proportion with caries-associated tooth loss (from 10.8 to 22.8%). Caries experience was greatest in the molar teeth and upper premolars, and was lowest in the lower anterior teeth. The mean crude caries increment (CCI) was 5.0 surfaces (SD 6.6); 681 (75.5%) experienced 1+ CCI, and the mean CCI among those individuals was 6.6 surfaces (SD 6.9). Substantial dental caries and tooth loss experience occur as people move from the third into the fourth decade of life.     

Time of Development of Occlusal and Proximal Lesions: Implications for Fissure Sealants

Analysis of surface and tooth-specific data from NHANES I and HHANES shows that the pattern of dental caries differs greatly from tooth to tooth and surface to surface. Occlusal caries precedes all other types, and increases most rapidly and to the highest levels in the molars. Caries on the proximal surfaces comes later. For sealants to be of value, they must reduce the need for restorations. Therefore, the value of sealants will be determined by the balance between high enough levels of potential caries on occlusal surfaces to give them something to prevent, and low levels of, or sufficiently delayed, proximal lesions to prevent the loss of the otherwise saved occlusal surface. The data presented demonstrate that as of the time of NHANES I, the number of permanent molars that could have had surfaces saved from restoration, at least for a number of years, appears to be sufficient to warrant widespread use of sealants on those teeth. More recent data (HHANES) suggest that the current decline in caries prevalence is likely to reduce the value of sealants in the short run because there are fewer occlusal lesions in young children, but may increase the value of sealants in the long run because proximal caries in older children and adults is also declining.     

Type 1 diabetes mellitus and oral health: assessment of coronal and root caries

OBJECTIVES: The oral health of a large cohort of adult insulin-dependent diabetic patients (Type 1), diagnosed 24 years previously with juvenile onset, was comprehensively assessed. This paper describes the prevalence of coronal and root caries in this adult Type 1 diabetic population and evaluates demographic, dietary, behavioral, physiologic, salivary and medical variables associated with decayed and filled surfaces in the crown (DFS) or root (RDFS). METHODS: Type 1 diabetes mellitus subjects participating in this oral health evaluation had been monitored for 6-8 years as participants in the University of Pittsburgh, Department of Epidemiology, longitudinal study of medical complications associated with diabetes. Four hundred and six diabetic subjects received a comprehensive oral health examination during one of their regularly scheduled medical visits. Oral assessments included coronal and root caries, missing teeth, edentulism, periodontal status, soft tissue pathologies, salivary function and health behaviors. Sixteen diabetic subjects and one control subject were edentulous. Coronal and root caries data from the remaining 390 dentate diabetic subjects were compared with 202 dentate nondiabetic control subjects. RESULTS: The adult Type 1 diabetic subjects were not found to have significantly higher DFS rates as compared with our control subjects or published age-adjusted NHANES III findings. Both control and diabetic subjects had low decayed to filled tooth surface ratios. A linear regression model evaluated possible associations with coronal decayed and filled tooth surfaces (DFS) within the diabetic population. Significant factors included older age, women, fewer missing teeth, more frequent use of dental floss, more frequent visits to the dentist during the last 12 months, and diabetic nephropathy. The prevalence of RDFS was higher in the diabetic subjects as compared to recruited control subjects. Neither dietary behaviors nor glycemic control were found to contribute to coronal or root caries. CONCLUSIONS: Factors associated with presence of coronal and root caries and fillings are discussed. Possible causes and implications for the association between DFS and diabetic nephropathy are provided.