Frail older adults and persons with special needs are at higher risk of oral diseases including dental caries. Considering the diverse background of the population, a personalized approach for each patient is mandatory to successfully manage their oral health needs. This article describes a succinct way to assess and categorize the risk of rapid oral health deterioration (ROHD) among this group. The procedures for assessing ROHD risk examine the ROHD risk categories, how risk factors impact treatment strategies, what techniques and materials exist for caries prevention and treatment, and how one effectively communicates caries management plans for this population.
Key points
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Frail older adults and persons with special needs include a diverse group of people with one or more disabilities that make them susceptible to rapid oral health deterioration (ROHD).
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The ROHD assessment helps practitioners determine the risk of oral health deterioration and identify how to deliver a personalized approach to dental care.
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ROHD risk factors are classified into three main categories: general health, social support, and oral conditions.
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ROHD risk levels are classified into four levels.
Introduction
The world’s population is aging, and this trend is not only pronounced but also historically unprecedented. In the next four decades, the world’s older adults (customarily, older adults are persons older than age 65 a
a However, aging has been defined as a biologic process and therefore older adults could be any person 21 years or older who may be biologically old.
) will increase from 800 million to 2 billion people. In general, the current cohort of older adults has been reported as healthier than previous ones. However, this progress has been unequal, and older adults still have more extensive health problems that require more intense health care for longer periods of time than younger people. As a consequence, the number of people living with disabilities increases with age. This poses an important challenge to health care systems around the globe.
In conjunction with population aging, there is also an increasing number of younger adults living with disabilities, which occurred because of a reduced mortality rate among disabled children and adolescents. In the United States, 10.5% of people aged 18 to 64 had some type of disability in the year 2015. The overall prevalence of people living with disabilities in the United States in 2015 was 12.6%, ranging from 9.9% in Utah to 19.4% in West Virginia.
Oral diseases are still highly prevalent in the global and US aging population. Because of population growth and aging, the cumulative burden of oral diseases has increased. Untreated caries in permanent teeth was the most prevalent chronic condition reported in 2015, affecting 2.5 billion people worldwide. In industrialized countries, oral health has improved for older adults in the last few decades, resulting in lower prevalence rates of caries, periodontal disease, and edentulism when compared with previous cohorts. However, the oral disease burden among older adults is still high, and caries has been shown to be an active disease among this population and even more so among frail older adults. It is explained in part by the fact that more older adults retain their teeth into old age, and gingival recession exposes more tooth surfaces to the risk of root caries. Thus, caries management among older adults should target preventing and controlling coronal and root caries, which has proved to be challenging.
Adults living with disabilities are exposed to different risk factors that negatively impact their oral hygiene routines, and their ability to access dental care, and consequently increases their risk of caries. These risk factors include but are not limited to cognitive impairment, dependence on caregivers, polypharmacy, poor manual dexterity, financial constraints, and xerostomia. The influence of these risk factors makes controlling dental caries among this population even more challenging.
It is important to prevent the development of caries among frail older adults and persons with special needs to avoid infection, pain, and tooth loss. These consequences of caries have been shown to impact systemic health and quality of life. To be successful in assessing and managing caries risk among these populations, one should consider all the patient modifying factors in a systematic way. In this article, the authors discuss how to provide a program of personalized and effective dental caries management for frail older adults and persons with special needs.
Rapid oral health deterioration
Frail older adults and persons with special needs are composed of a wide diversity of people with different health problems, which require different types and intensities of care. In an initial attempt to help clinicians to determine the level of care necessary for different older adults, the aging population was classified into three groups: (1) functionally independent older adults, who can access oral health care on their own (70% of people older than age 65) ; (2) frail older adults, who can access oral health care with help from others (20% of people older than age 65) ; and (3) functionally dependent older adults, who benefit most if oral health care is provided in their place of residency (5% are homebound and 5% are nursing home residents). This classification b
b This classification is based on national US disability data, but is similar in many industrialized Western countries.
proved to be important because each category requires a different philosophic approach to care, depending on the patient’s modifying factors, which may range from the most sophisticated and technical treatment available to no treatment at all. More recently, Chi and Ettinger presented a more extensive approach encompassing six distinct life periods, from early childhood to older adulthood, when discussing oral health–related issues with regard to caries prevention for people with special needs. A unifying approach that considers all risk factors for the entire population of frail older adults and persons with special needs is still lacking.
Recently, a systematic approach to teach dental students how to assess the risk of rapid oral health deterioration (ROHD) was introduced. This approach used education theory to develop a learning guide aimed at reproducing the expert’s thought process when assessing frail older adults or persons with special needs, and is also used by more experienced dental practitioners. The strategy depends on evidence-based risk factors collected from the dental literature that have been shown to increase the risk of ROHD. It also includes a learning guide to help the practitioner to evaluate the risk, present customized treatment alternatives, and communicate plans to patients and/or their caregivers. The most common evidence-based ROHD risk factors among frail older adults and persons with special needs are described next.
Rapid oral health deterioration risk factors
Evidence-based risk factors for ROHD is classified into three categories: (1) general health, (2) social support, and (3) oral conditions. These risk factors are also referred to as modifying factors ( Box 1 ), and influence treatment decisions either independently or are multifactorial.
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Risk Factors/Modifying factors
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General health conditions
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Cognitive deficits: Alzheimer disease and other dementias
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Functional deficits: stroke, osteoarthritis, Parkinson disease, and so forth
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Sensory losses: speech, sight, hearing, and taste
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Medications: oral and systemic side effects, drug interactions
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Manageable chronic diseases: hypertension, diabetes, osteoporosis, and so forth
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Degree of dependence/autonomy: institutionalization, home care, dependence on caregivers, and so forth
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Terminal diseases/palliative care
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Life expectancy
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Social support
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Institutional support
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Family/social support
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Financial issues: private insurance, Medicare, Medicaid, social security, and so forth
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Transportation
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Access to care
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Education and oral health literacy
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Informed consent
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Expectations
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- 3.
Oral conditions
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Oral hygiene: independency or dependency
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Periodontal condition
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Caries
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Number of teeth/restorations, number of chewing pairs
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Prosthetic status: fixed, removable, implants
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Oral lesions: inflammation, oral cancer
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Stop seeing the dentist
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- 1.
General Health
The ROHD risk factors in this category are usually collected by oral health providers through health history forms, medication lists, and the initial interview with the patient. For example, there are multiple diseases that reduce patients’ ability to maintain a proper oral hygiene routine, and thus increase patients’ likelihood of experiencing ROHD, such as congenital (ie, cerebral palsy) and acquired physical (ie, rheumatoid arthritis) deficits.
Patients’ ability to keep adequate oral hygiene routines are limited by cognitive deficits, because patients may not be able to remember to perform oral hygiene, do not know how to do it, or are not able to appreciate the importance of having good oral hygiene. Developmental disabilities, such as Down syndrome and autism spectrum disorders, can cause cognitive deficits. Later in life, such diseases as Alzheimer disease and other dementias can also cause cognitive deficits. Additionally, cognitive deficits can prevent patients from communicating oral pain or discomfort, providing informed consent, adapting to dentures, and adhering to treatment and maintenance plans.
Keeping good oral hygiene routines can also be more difficult for patients with functional deficits, such as patients who have had a cerebrovascular accident, patients who are quadriplegic, have cerebral palsy, and advanced Parkinson disease, and also patients with severe osteoarthritis or rheumatoid arthritis. Although some of these conditions may also have a cognitive component, manual dexterity is compromised even if there is no cognitive deficit, reducing the patients’ capacity to perform appropriate oral hygiene by themselves ( Figs. 1 and 2 ).
Some conditions/diseases predispose patients to more aggressive oral disease. Immunocompromising conditions, such as AIDS, patient taking immune-suppressant drugs, or anticancer chemotherapeutic agents, and uncontrolled diabetes are examples of conditions that predispose patients to more aggressive oral disease, thus increasing patients’ risk of ROHD. Polypharmacy used to control different diseases and/or its symptoms can also lead to reduced salivary flow, which is another condition that has been frequently linked to more aggressive oral disease among frail older adults and persons with special needs.
Sensory impairments (mainly sight, hearing, taste, and proprioception) can also reduce patients’ ability to perform appropriate oral hygiene. If patients cannot see, plaque removal may be incomplete, or if patients do not hear well they may not adhere to treatment maintenance plans because they do not fully understand what has been discussed. Taste and proprioceptive changes can impact patients’ ability to adapt to dentures. Patients with autism spectrum disorders often present with sensory challenges that can benefit from appropriate sensory adaptations when providing dental care.
Mental health conditions have also been shown to impair patients’ capacity of maintaining appropriate oral hygiene, providing informed consent, and adhering to treatment and maintenance plans. Some of the important factors that might impact oral health care for patients with serious mental health conditions are the type and severity of the illness; mood, motivation, and self-esteem; lack of oral health perception; lack of self-discipline to maintain daily oral hygiene; and side effect of medications. Destructive habits, such as smoking, poor diet, and substance abuse, are also common issues associated with people with mental disabilities. Although poor oral health findings are common among people with mental health problems and many barriers for appropriate oral health care have been identified, no current investigation has identified enablers to improve oral health care.
Among the different mental health diseases, depression is of special interest because it is particularly prevalent among older adults and can increase the risk for ROHD not only by discontinuing daily oral hygiene, but also because of the strong xerostomic effect of the use of antidepressants. Another group of mental health conditions associated with increased risk of ROHD are the eating disorders, which can cause dental erosion. Dental erosion is also often seen associated with gastroesophageal reflux disease, which is prevalent among individuals with developmental disabilities.
Providers should be aware that multiple general health-related risk factors are often found in frail older adults and patients with special needs, for instance survivors of a cerebrovascular accident may have concomitant cognitive and functional deficits. Also, depression is common in early dementia and these cognitive impairments may be by aggravated polypharmacy-induced xerostomia.
Social Support
Social support–related risk factors for ROHD are most commonly overlooked by oral health practitioners. Nevertheless, ROHD risk factors related to the patients’ social support may play an important role in facilitating or making it more difficult for patients to access appropriate oral health care, maintain daily oral hygiene, and adhere to a proposed treatment plan.
Lack of income has been reported as an important barrier for health care use. The families of frail older adults and patients with special needs have a higher economic burden as compared with families without members with special care needs, therefore discretionary finances may not be available to access health care. In addition to treatment cost, paying for transportation and parking is an added barrier. In addition, lack of dental insurance has also been cited as another important barrier to care.
Another social support–related risk factor is patients’ dependency on caregivers, which is considered the major barrier for receiving appropriate daily oral hygiene and accessing oral health care. Caregivers are anyone from a family member to a nursing aid, who provides care at the patient’s home or in a long-term care facility. The level of care provided varies depending on the severity of the disability and the willingness of the patient to cooperate. Many factors have been reported to influence the provision of this care, including the caregivers’ level of training and their oral health literacy. Institutionalization is another important risk factor for ROHD, because most of the long-term care facilities lack appropriate oral hygiene routines and have been resistant to many different strategies suggested to improve the provision of oral care.
Community-level factors that should be considered as risk factors of ROHD include access to community water fluoridation, healthy foods (including buying, preparing, and eating), and access to dental providers with appropriate training.
Other important risk factors related to social support are the stigma and prejudice against frail older adults and persons with special needs. Stigma related to people with mental conditions has been reported as a significant barrier for accessing adequate care. Ageism (defined as “the stereotyping, prejudice and discrimination toward people based on age”) has also been described by the World Health Organization as one of the most important barriers for providing age-appropriate care for the growing number of older adults. Ageism has been shown to be pervasive among health professions, and dentistry is no exception.
The lack of interprofessional collaborative practice among health care providers has been cited as a barrier for receiving appropriate care for frail older adults and persons with special needs. For these patients, it is important to assess how they function in their environment and how dentistry fits into their lifestyle and overall treatment/management goals. To make these assessments requires interprofessional collaboration, which is necessary to integrate several different disciplines to achieve good outcomes. Because these patients often have a multitude of health conditions, each requiring unique therapies and different providers, communication between providers is necessary to understand the patient’s needs and prevent overtreatment or undertreatment.
Oral Conditions
Some oral health conditions encountered among frail older adults and persons with special needs can also increase their risk for ROHD. Xerostomia is a common oral health condition that predisposes patients to oral health decline, and is usually caused by polypharmacy. Other causes for xerostomia include systemic diseases (eg, diabetes), psychoaffective disorders, head and neck radiation, and autoimmune diseases (eg, Sjögren syndrome).
It is important to realize the difference between xerostomia, which is the subjective symptom of having a dry mouth reported by the patient, and salivary gland hypofunction, which is the reduced salivary flow that is measured by quantifying the amount of saliva produced in a given time. It is advisable to measure xerostomia and salivary gland hypofunction in a patient where xerostomia is contributing to ROHD. Thus, a question about dry mouth sensation in the patient health history can help determine the need for assessing salivary flow output.
Xerostomia prevalence among older adults ranges from 12% to 39%, with a weighted average of 21%, which shows xerostomia is a common condition in this population. The prevalence of xerostomia among younger adults is estimated to be about half of that compared with older adults. Xerostomia impacts patient speech, taste, swallowing, eating, and wearing dentures. Additionally, xerostomia can also contribute to halitosis, burning mouth sensation, and increases the caries risk.
In addition to xerostomia, other oral conditions can also lead to an increased caries risk. Among older adults, the cumulative nature of gingival recession and consequent root surface exposure in later life is a major risk factor for root surface caries. Other risk factors include poor plaque control and previous experience with coronal and root caries. Wearing partial dentures and having a heavily restored dentition are also risk factors for ROHD. Among younger adults with special needs, enamel defects, which is associated with some developmental disabilities, have also been linked to increased caries risk and further ROHD. Another local risk factor is the use of liquid medications with high sugar content for patients who are unable to swallow tablets.
Rapid oral health deterioration risk assessment
The ROHD risk assessment was designed on the premise that patients with disabilities can have a combination of risk factors, which can lead to a rapid decline in oral health. Because of the complexity of their health conditions, older adults and patients with special needs who have a high caries prevalence may not improve their oral health by simply instructing the patients to brush their teeth. It is only with a complete understanding of all the risk factors affecting a patient that caries risk can be improved, treatment can be effectively provided, and prevention can be improved. The assessment of the ROHD risk and selection of appropriate course of treatment to deter or manage the risk can be done in a systematic way.
The first step is gathering information concerning ROHD risk factors. At this point, the oral health provider should be able to assess the completeness of the data gathered from the patient/caregiver interview, health history form, medication list, intraoral examination and radiographic evidence, and from the caries risk assessment. If any important information regarding one of the three categories of risk factors (ie, general health, social support, and oral conditions) is missing, it should be supplemented at this time.
The second step prioritizes the already gathered information. From all the general health conditions, social support factors, and oral health conditions presented by the patient, the clinician needs to decide which ones are more likely to contribute to ROHD progression and help determine the treatment plan. For example, if an adult patient with Down syndrome presents with controlled type II diabetes mellitus and is able to carry out his/her own daily oral hygiene at a reasonable level, it is less likely that diabetes will influence oral disease progression and modify the treatment plan. But if the same patient presents with signs of early dementia, this information is likely to increase the patient’s risk for ROHD and also influence the treatment plan to increase preventive measures and recruit future caregivers to help with oral hygiene, because self-care is expected to decline as the dementia progresses.
The third step categorizes the patient’s current ROHD stage to predict the future oral health of the patient if no dental treatment is provided, or whether an alternative treatment approach may be needed. This step helps the provider to understand and manage the patient’s disease as a continuum, and therefore there is a need to explain to the patient and the caregiver the importance of the dental treatment plan. As a guide for the oral health provider, ROHD is classified into four categories depending on the severity of the risk factors and the disease progression:
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Risk factors are not present, therefore no ROHD is occurring
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Risk factors are present, however, ROHD is not currently occurring
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Risk factors are present, and ROHD is currently occurring
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Risk factors are present, and ROHD has already occurred
This ROHD classification helps determine the preventive and restorative approaches needed in the treatment plan. However, there are often no clear demarcations between the stages, and patients may be transitioning from one stage to another. Therefore, thinking about risk factors as they relate to disease progression and how they impact treatment planning for a given patient is the emphasis of this step.
The fourth step identifies the treatment alternatives, recommending a specific intervention with a rationale, and then developing a communication plan for the patient, caregivers, and other members of the health care team. These topics are discussed in further detail in the next section of this article. Box 2 summarizes treatment planning using the ROHD assessment.
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Step 1. Gathering information concerning ROHD risk factors
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Step 2. Prioritizing the information (What matters most?)
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Step 3. Categorizes risk for ROHD
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ROHD risk categories
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Risk factors are not present, therefore no ROHD is occurring
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Risk factors are present, however, ROHD is not currently occurring
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Risk factors are present, and ROHD is currently occurring
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Risk factors are present, and ROHD has already occurred
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What will happen if I do nothing?
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Step 4. Identify possible treatment alternatives
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