An Expert Opinion from the European College of Gerodontology and the European Geriatric Medicine Society: European Policy Recommendations on Oral Health in Older Adults

This is an expert opinion paper on oral health policy recommendations for older adults in Europe, with particular focus on frail and care‐dependent persons, that the European College of Gerodontology (ECG) and the European Geriatric Medicine Society (EUGMS) Task and Finish Group on Gerodontology has developed. Oral health in older adults is often poor. Common oral diseases such as caries, periodontal disease, denture‐related conditions, hyposalivation, and oral pre‐ and cancerous conditions may lead to tooth loss, pain, local and systemic infection, impaired oral function, and poor quality of life. Although the majority of oral diseases can be prevented or treated, oral problems in older adults remain prevalent and largely underdiagnosed, because frail persons often do not receive routine dental care, due to a number of barriers and misconceptions. These hindrances include person‐related issues, lack of professional support, and lack of effective oral health policies. Three major areas for action are identified: education for healthcare providers, health policy action plans, and citizen empowerment and involvement. A list of defined competencies in geriatric oral health for non‐dental healthcare providers is suggested, as well as an oral health promotion and disease prevention protocol for residents in institutional settings. Oral health assessment should be incorporated into general health assessments, oral health care should be integrated into public healthcare coverage, and access to dental care should be ensured.     

Illicit drug use and oral health

People with drug use disorders (PWDUD) have elevated prevalence of oral diseases, in particular dental caries (tooth decay), periodontal (gum) disease and xerostomia (dry mouth). When left untreated, these oral health conditions may progress and lead to tooth ache, abscesses and tooth loss, and in turn, to poor chewing functioning and digestion, dental aesthetic problems and reduced wellbeing. Illicit drug use may, per se, cause xerostomia, which in turn increases vulnerability for dental caries. However, the other main drivers of oral diseases and their progression—poor oral hygiene, frequent sugar intake and infrequent dental visits—can mainly be ascribed to the irregular lifestyle, poor economy and mental health problems that often accompany illicit drug use. Establishment of good oral health habits is essential in the dental care for PWDUD. Dental treatment is often comprehensive and challenging; because the patients may have extensive treatment needs but also difficulties adhering to preventive measures and dental appointments. An integrated care approach for PWDUD would likely benefit both their oral and general health.     

The strength of age effect on tooth loss and periodontal condition in Korean elderly

Aging is a well-known risk factor associated with oral diseases. The aim of this cross-sectional study was to compare tooth loss and periodontal health between the relatively young elderly (65-74 years) and the old elderly (≥75 years) and to investigate the strength of the age effect on oral health status in the Korean elderly. Study population 65 years of age or older were selected from the participants of the Korean National Oral Health Survey (2006) (n = 1193). Oral examination was conducted by eight dentists trained in the World Health Organization (WHO) recommended examination procedure. The chi-square test, multiple regression analyses and multinomial logistic regression analyses were performed using SAS 9.1.3. The oral health status including decayed, missing, and filled teeth (DMFT), missing teeth, and residual teeth significantly differed between the young elderly and the old elderly (p < 0.01). Moreover, the regression coefficients of tooth loss linearly increased across different age groups (5-year intervals, starting at age 65 years) (p < 0.05). However, the odds ratios of periodontal health did not significantly differ across 5-year interval age groups. The findings that age and the number of missing teeth are significantly and linearly related could contribute to the development of oral health care and promotion programs for the elderly tailored to their own age.     

2型糖尿病患者缺牙及义齿修复相关因素临床研究

目的：探讨2型糖尿病患者缺牙及义齿修复的相关因素。方法选取126例研究对象,其中2型糖尿病63例作为糖尿病组,非糖尿病人63例作为对照组,比较两组缺牙数、牙周病牙数及龋病牙数等相关指标的差异。调查两组牙列缺损及义齿修复情况,分析糖尿病人缺牙的相关因素。结果糖尿病组缺牙数、牙周病牙数及复杂牙列缺损病例数均较对照组增多,差异有统计学意义（ P＜0.05）。 Logistic多元逐步回归分析表明,两组在牙周病牙数、复杂牙列缺损病例数及定期口腔健康检查例数方面的差异也具有统计学意义（ P＜0.05）。结论糖尿病组缺牙数、牙周病牙数及复杂牙列缺损病例数较对照组明显增多,多因素分析结果表明牙周病牙数、复杂牙列缺损例数及定期口腔健康检查与糖尿病缺牙关联密切。     

The systemic oral health connection: Biofilms

Frequently, periodontal health and it’s associated oral biofilm has not been addressed in those patients who have systemic health issues, especially those who are not responding to medical treatment via their physician. Oral biofilm may be present in the periodontal sulcus in the absence of clinical disease of periodontal disease (bleeding on probing, gingival inflammation) and periodontal reaction is dependent on the patient’s immune response to the associated bacterial and their byproducts. Increasing evidence has been emerging the past decade connecting oral biofilm with systemic conditions, either initiating them or complicating those medical conditions. The patient’s health needs to be thought of as a whole-body system with connections that may originate in the oral cavity and have distant affects throughout the body. To maximize total health, a coordination in healthcare needs to be a symbiosis between the physician and dentist to eliminate the oral biofilm and aid in prevention of systemic disease or minimize those effects to improve the patient’s overall health and quality of life. Various areas of systemic health have been associated with the bacteria and their byproducts in the oral biofilm. Those include cardiovascular disease, chronic kidney disease, diabetes, pulmonary disease, prostate cancer, colon cancer, pancreatic cancer, pre-term pregnancy, erectile dysfunction Alzheimer’s disease and Rheumatoid arthritis. This article will discuss oral biofilm, its affects systemically and review the medical conditions associated with the oral systemic connection with an extensive review of the literature.     

Type 1 diabetes and oral health: Findings from the Epidemiology of Diabetes Interventions and Complications (EDIC) study

ObjectiveTo describe long-term oral health outcomes and examine associations between sociodemographic factors, clinical characteristics, and markers of diabetes control on tooth loss in participants with type 1 diabetes enrolled in the Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications (DCCT/EDIC) study.Research design and methodsOral health outcomes related to tooth loss were reported at annual visits during EDIC years 22–26 (2015–2019). Generalized estimating equation models were used to assess the association of individual risk factors and tooth loss, over repeated time points.ResultsA total of 165 (17%) participants with type 1 diabetes reported 221 oral health outcomes related to tooth loss over a five-year period. After controlling for age and current tobacco use, the presence of diabetic peripheral neuropathy was significantly associated with an increased odds of tooth loss (OR = 1.88, 95% CI 1.24, 2.87) while higher mean HDL/LDL cholesterol ratio was significantly associated with a decreased odds of tooth loss (OR = 0.87, 95% CI = 0.79, 0.97).ConclusionsThese findings suggest that diabetes-related complications, either resulting from or independent of poor glycemia, may be directly associated with oral health conditions, and support the need for individuals with type 1 diabetes and providers to implement lifestyle and medical interventions to reduce oral health risks.     

The features of degenerative diseases and their association with the loss of teeth in the elderly of East Jakarta (Indonesia)

This epidemiological survey was conducted to find features of degenerative diseases associated with loss of teeth in the elderly. One hundred sixty-seven elderly (> or = 60 years old) people from local government health centers in East Jakarta, Indonesia were included in the study. The degenerative diseases (DM, hypertension, heart disease) were determined by physical examination, laboratory testing and questionnaires. Tooth loss was measured by the DMF-T (decay, missing, filling teeth) index. Oral hygiene condition was based on OHI-S (oral hygiene index simplified) index. The most common degenerative disease was hypertension (45.5%). DM was found a few (3.6%). Approximately 55% of respondents had moderate oral hygiene problems. The demand for professional dental care was low. There was no significant association between degenerative diseases and the loss of teeth. In conclusion, the loss of teeth was not associated with degenerative diseases, but may have been influenced by local factors such as a low demand for dental hygiene.     

Dentistry supports eating function in the aged

As demographic aging continues even today, geriatric dentistry responsive to the times must be established. The greatest concern of elderly individuals is health, and as dentists, we care for the oral cavity as the gateway to the digestive organs. Stated briefly then, I believe that our primary role as dental health care providers in an elderly society is to maintain and promote health by preventing a decline in eating function. Dentistry up to the present has pursued responses to disease. But in an elderly society, a decline in oral function accompanying aging is a problem. In other words, consistent with changes in the population structure, dentistry in the future should not end with the treatment of tooth decay, periodontal disease, or other such dental diseases; rather, it must pursue a shift to prevention of age-attendant decline in oral function and maintenance of healthy food intake and swallowing functions. Nonetheless, dentistry is gradually declining in hospitals that admit elderly individuals. While urban dental clinics are regarded as too numerous, dentistry in hospitals is disappearing, and the thought of health care settings without dentistry is sobering. I believe we must eliminate a troubling situation in which our connection to dentistry is severed at a time when we most need dentistry. This should be the first step in establishing dentistry for maintenance of eating functions.     

Socio-demographic factors and oral health conditions in the elderly: A population-based study

The aim of the present study was to analyze the relationship between oral health conditions and socio-demographic factors in an elderly population from Macaíba/RN (Brazil). A questionnaire was used to characterize the socio-demographic profiles and a clinical examination was performed to assess oral health conditions such as tooth decay, gum disease, use of dental prosthesis, need for dental prosthesis and soft tissue injuries. The technique of random sampling by conglomerates was used, taken from randomly selected census drafts, with a total sample of 441 individuals. The prevalence of edentulism, bleeding and dental calculus was 50.8%, 27.2% and 32%, respectively, excluding all sextants in 59% of the elderly. Data analysis was conducted using the chi-squared test with the level of significance set at 5%. Prior to association tests, the dependant variables were submitted to principal component analysis. Four factors were extracted to represent the oral health conditions of elderly individuals. A statistically significant association was found between the following variables: gender and the presence of a caregiver with gum disease; age, residence area, presence of a caregiver and household density with need for dental prosthesis; and household density with soft tissue injuries. Therefore, precarious oral health conditions were found among the elderly and associations were found between these conditions and the socio-demographic factors, particularly gender, age and residence area. The results obtained demonstrated the need for improved oral health conditions in the elderly. The study of these conditions, allied to socio-demographic factors, is important in terms of both dental care and public policy planning related to these individuals.     

Socio-demographic factors and oral health conditions in the elderly: A population-based study

The aim of the present study was to analyze the relationship between oral health conditions and socio-demographic factors in an elderly population from Macaíba/RN (Brazil). A questionnaire was used to characterize the socio-demographic profiles and a clinical examination was performed to assess oral health conditions such as tooth decay, gum disease, use of dental prosthesis, need for dental prosthesis and soft tissue injuries. The technique of random sampling by conglomerates was used, taken from randomly selected census drafts, with a total sample of 441 individuals. The prevalence of edentulism, bleeding and dental calculus was 50.8%, 27.2% and 32%, respectively, excluding all sextants in 59% of the elderly. Data analysis was conducted using the chi-squared test with the level of significance set at 5%. Prior to association tests, the dependant variables were submitted to principal component analysis. Four factors were extracted to represent the oral health conditions of elderly individuals. A statistically significant association was found between the following variables: gender and the presence of a caregiver with gum disease; age, residence area, presence of a caregiver and household density with need for dental prosthesis; and household density with soft tissue injuries. Therefore, precarious oral health conditions were found among the elderly and associations were found between these conditions and the socio-demographic factors, particularly gender, age and residence area. The results obtained demonstrated the need for improved oral health conditions in the elderly. The study of these conditions, allied to socio-demographic factors, is important in terms of both dental care and public policy planning related to these individuals.     

The pathological oral cavity as a preventable source of postoperative pneumonia in thoracic surgery: a prospective observational study

BackgroundPneumonia after thoracic surgery considerably contributes to perioperative morbidity and mortality. So far, the forced expiratory volume in one second and diffusing capacity of the lungs for carbon dioxide are the most common validated prognosticators to estimate individual risk. Beyond functional parameters, modifiable risk factors for respiratory complications like pneumonia are poorly investigated in a prospective way. Thus, we aimed to assess the impact of oral health status in patients undergoing thoracic surgery and its correlation to perioperative outcomes.MethodsA prospective observational study included adult patients undergoing elective thoracic surgery from October 2, 2018 to April 29, 2020. The day before surgery, patients were examined by a dentist. Oral health status (caries, periodontal disease, tooth loss, and regular dental visits) was correlated with perioperative outcomes.ResultsDuring the study period, 230 consecutive patients were included. Oral health status was poor in the study population. Postoperative complications were associated with active caries [odds ratio (OR) 2.5, P<0.03]. Patients with frequent dental visits and treated teeth had a lower risk for postoperative complications compared with patients without regular visits (OR 0.3, P<0.02). Patients with a high burden of caries had a significantly increased risk for pneumonia (OR 7.9, P<0.002). The forced expiratory volume in one second was a significant prognosticator for postoperative complications; however, no association between the forced expiratory volume in one second and oral health parameters was observed.ConclusionsA pathological oral health status is a modifiable factor predicting postoperative complications and pneumonia. A prospective randomized interventional study is warranted to clarify whether an improvement in oral health status can lead to a reduction of perioperative risk.     

An approach to oral infections and their management

Oral infections can be odontogenic or nonodontogenic in origin. Odontogenic infections are most prevalent and include dental caries, periodontal disease, and suppurative deep space infections. Nonodontogenic infections include sialadenitis and parotitis, vesiculobullous gingivostomatitis, aphthous ulcers, oropharyngeal candidiasis, and severe oral mucositis in the immunocompromised host. Clinical presentations can be variable. An understanding of the underlying anatomic structures, the oral microflora, and associated medical conditions of the host is critical to guide appropriate diagnosis and management. In this paper, preventative strategies to reduce dental plaque formation and promote oral health are emphasized.     

General dental care for the elderly.

In order to provide the highest level of quality medical care, the physician must be knowledgeable about problems related to the oral cavity. In particular, the physician should understand how to identify specific oral and dental problems such as caries, periodontal disease, and mucosal lesions, refer to and consult with dental health professionals regarding oral health issues, and be aware of the range of dental treatment modalities for oral and dental problems.     

Tooth loss and dental prostheses in the oldest old

Along with the increasing life expectancy is a trend that elderly adults retain their natural dentition until later in life. However, tooth loss and its consequences remain a reality in the geriatric population. Poor oral health and neglect of hygiene measures often lead to rapid decay of the dentition. Multiple comorbidities and the subsequent intake of numerous drugs may cause xerostomia and thus accelerate tooth loss. Bacterial plaque also constitutes a risk for aspiration pneumonia. The relations between tooth loss and the psychosocial well being, general health, chewing efficiency and mortality are well documented but the underlying mechanisms are not fully understood yet. The slow and gradual loss of chewing function often leads to an unnoticed change in diet by avoiding foodstuffs, which are difficult to manage. This is of particular concern in malnourished geriatric patients. Not every missing tooth needs replacement, but restorative dental treatment remains frequent among the oldest old. Well-made dentures help increasing the patient's oral health related quality of life and optimize oral function. Restorative dental treatment should be complemented by nutritional counseling to improve nutritional intake. Once fitted, dentures need to be closely monitored for retention, stability, structure and hygiene. Progressing alveolar ridge resorption may require a denture reline. Furthermore, pathologies of the oral mucosa demand regular dental check-up visits. In edentate oldest old, well-made dental prostheses may play a key role in limiting morbidity and supporting successful ageing.     

Vulnerability and the Psychosocial Aspects of Tooth Loss in Old Age: A Southern Brazilian Study

Extensive tooth loss and edentulism can have a negative impact on the general health and quality of life of older adults. The extent to which psychological and social factors affect an individual's decision to undergo tooth extraction and mouth clearance (extraction of all teeth), and the theoretical relationships between social structure, social life and oral health can be unraveled through qualitative research. This study aimed to explore the social and psychological factors involved in tooth extraction and mouth clearance within a historical perspective among rural Southern Brazilian older adults. It is based on qualitative data gathered via a series of eight focus groups among 41 older adults. Underlying the focus group discussions of different levels of health risks and resources for prevention of disease was the concept of vulnerability. Participants' responses illustrated that tooth loss and mouth clearance were related to a lack of public dental health policies and programs, were influenced by social norms (including values pertaining to gender), and were associated with a low level of oral health knowledge. The social and program-dependent contexts of vulnerability were shown to have played a major role in the development of norms and values towards tooth extraction and mouth clearance. Vulnerability must be reduced in order to prevent disease particularly among rural populations. The influence of fatalistic beliefs about the inevitable loss of teeth with age may negatively influence the acceptance of dental treatment and predilection for oral health self-care.     

Periodontal diseases

The periodontal diseases are highly prevalent and can affect up to 90% of the worldwide population. Gingivitis, the mildest form of periodontal disease, is caused by the bacterial biofilm (dental plaque) that accumulates on teeth adjacent to the gingiva (gums). However, gingivitis does not affect the underlying supporting structures of the teeth and is reversible. Periodontitis results in loss of connective tissue and bone support and is a major cause of tooth loss in adults. In addition to pathogenic microorganisms in the biofilm, genetic and environmental factors, especially tobacco use, contribute to the cause of these diseases. Genetic, dermatological, haematological, granulomatous, immunosuppressive, and neoplastic disorders can also have periodontal manifestations. Common forms of periodontal disease have been associated with adverse pregnancy outcomes, cardiovascular disease, stroke, pulmonary disease, and diabetes, but the causal relations have not been established. Prevention and treatment are aimed at controlling the bacterial biofilm and other risk factors, arresting progressive disease, and restoring lost tooth support.     

A systematic review of the effectiveness of oral health promotion activities among patients with cardiovascular disease

Aims

This study aimed to review the effectiveness of oral health promotion activities conducted among patients with cardiovascular disease.

Methods and results

Three electronic databases were searched for effective papers using standardized search methods, and key findings of effective studies were summarized. The initial search yielded 3101 papers but only 8 studies met the criteria for this review: 3 were randomized controlled studies, 3 were pre-/post group interventions, 1 was a randomized split-mouth study, and 1 was a quasi-experimental study. Studies retrieved concerned oral health promotion activities in patients with coronary heart disease, hypertension, heart transplantation, and stroke. Interventions comprised periodontal treatment performed by dental personnel, and oral hygiene interventions provided by nursing home care assistants. Outcomes included improvements in periodontal health, and modifications of systemic inflammatory markers. No studies, however, evaluated the effects of oral health promotion interventions on oral microflora.

Conclusion

There are limited studies on the efficacy of oral health promotion activities in patients with cardiovascular disease, particularly stroke patients. Oral health promotion activities appear to produce improvements in periodontal health, and also result in changes to systemic markers of inflammation and endothelial function (at least) in the short term. Whether these effects can ultimately lower the risk of secondary cardiovascular events has not yet been determined.     

Oral health considerations in older women receiving oral bisphosphonate therapy

Recent reports of bisphosphonate-related osteonecrosis of the jaw (BRONJ) have increased awareness of oral health in patients receiving osteoporosis therapy. This study describes the demographic, oral health, and clinical characteristics of a contemporary population of women aged 50 and older undergoing oral bisphosphonate treatment who returned a mailed questionnaire pertaining to dental symptoms. The study, as previously reported, was conducted within Kaiser Permanente Northern California, a large, integrated healthcare delivery system. The cohort included 7,909 women with bisphosphonate exposure of at least 1 year, with a subset of 923 women reporting dental symptoms who underwent clinical examination. Overall, the average age was 71 ± 9; 70% were white, and 74% had at least some college education. Nearly two-thirds had received oral bisphosphonate therapy for 3 or more years. Most reported daily tooth brushing, 85% had had a dental examination in the past year, 22% reported denture use, and 6% reported moderate to severe periodontal disease. Oral healthcare patterns varied according to age and race and ethnicity. Five hundred seven (6.4%) women reported a tooth extraction in the prior year, of whom two developed BRONJ (0.4%). Tori or exostoses were found in 28% of examined participants with dental symptoms; these were predominantly in the lingual mandible and palate, with palatal BRONJ occurring in 1.6% of symptomatic participants with palatal tori. In summary, among older women with bisphosphonate exposure, oral health varied according to patient characteristics, and BRONJ occurred more frequently after tooth extraction or on palatal tori. These data support efforts to optimize oral health and to identify risk factors for BRONJ in older individuals receiving bisphosphonate drugs.     

Development of Web-based intervention system for periodontal health: a pilot study in the workplace

BACKGROUND: It has recently been accepted that periodontal disease is a risk factor for not only tooth loss but also systemic diseases. An effective system of public intervention for periodontal health to enable continuous intervention of dental professionals has been sought. We developed a Web-based intervention system regarding periodontal health and evaluated the effects of the system in the workplace. METHODS: The system was capable of storage and display of personalized oral health records including video images pertaining to toothbrush manipulation within their own oral cavities based on instructions by dental professionals. The system enabled clients to view movement of their own skill, and repeatedly. Thirteen workers of a company were randomized to either an experimental or control group. The control group received face-to-face toothbrushing instruction at the company and follow-up via telephone. The experimental group received follow-up through our system in addition to those components employed in the control group. MAIN RESULTS: The workers in the experimental group benefited in terms of improvements of not only plaque removal but also periodontal health over 3 months. CONCLUSIONS: These results indicate that implementation of an Web-based approach for periodontal health affords the possibility of remote instruction and produces additional public benefit.