Poor oral health in the geriatric population is being framed as a potentially new geriatric syndrome; an oral and maxillofacial geriatric syndrome. As such, the treatment of oral diseases will require a comprehensive approach that considers the multimorbidity of disease, and polypharmacy that is precipitated/exacerbated by oral and maxillofacial dysfunction. This is challenging because oral diseases are not 1 discrete systemic illness but a combination of many with common causes. This article presents a roadmap approach to evaluate symptoms and apply therapeutic strategies for 5 common oral and maxillofacial dysfunctions seen in the elderly.
Key points
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Poor oral health in the geriatric population is being framed as a potentially new geriatric syndrome; an oral and maxillofacial geriatric syndrome.
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The article presents a roadmap approach using the concepts of the geriatric syndrome to apply therapeutic strategies for 5 common oral and maxillofacial dysfunctions seen in the elderly.
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The concept of the geriatric syndrome describes an innovative and well-tested approach in managing the interplay of age-related physiologic changes, chronic disease, functional stressors, and oral health in the elderly.
Introduction
The World Health Organization (WHO) has calculated that the global population is increasing at an annual rate of 1.7%, whereas those who are aged 65 years or older are increasing at a rate of 2.5%. By the year 2050, 1 out of 5 persons in the United States will be aged 65 years or older. These demographic projections will have a major impact on delivery of both general and oral health care, as well as how providers tailor treatment strategies within the elderly patient population. Oral and maxillofacial health affects systemic health, as well as different aspects of life with respect to social interaction, self-esteem, and the health-related quality of life for the geriatric population. Although many people aged 65 years or older remain healthy and visit medical/dental providers either infrequently or for health maintenance care, their cohorts experience increased rates of age-related physiologic changes in the oral cavity, changes caused by the comorbidities of chronic illnesses and changes resulting from medications used to manage diseases.
With an aging population, oral health care providers need to understand and apply the concepts of geriatrics to the delivery of oral health care. The concept of geriatric syndromes forms a framework for addressing the complex oral health needs of older adults and the managing of certain common geriatric oral syndromes, such as increased caries risk, periodontitis and its nexus with systemic disease, disorders in taste and swallowing, dysfunction in chewing and speaking (or mandibular dyskinesia/dystonia), and burning mouth syndrome (BMS).
Geriatric syndrome/geriatric 5Ms/frailty
Geriatric syndromes refer to “multifactorial health conditions that occur when the accumulated effects of impairments in multiple systems render [an older] person vulnerable to situational challenges.” The common geriatric syndromes, such as falls, functional decline, delirium, incontinence, polypharmacy, and frailty, are also described as “clinical conditions in older people that do not fit into discrete disease categories.” The geriatric provider’s usage of the term syndrome emphasizes multiple causations of a unified manifestation. With this usage, the conceptualization of geriatric syndromes aligns itself well with the “the observable characteristics, at the physical, morphologic, or biochemical level, of an individual, as determined by the genotype and environment.” As such, it is multifactorial; that is, involving the interaction among stressors and age-related risk predictors that can have a devastating effect on multiple organ systems ( Fig. 1 ). Frailty is “a common and important geriatric syndrome associated with age-related declines in physiologic reserve/function across multi-organ systems.” The frailty phenotype is applied when 3 or more of the following occur: weakness, a slow level of physical activity, poor endurance, breakdown in several inflammatory cascades, and weight loss.
Although there is no single definition of polypharmacy, it consists of the use of several medications simultaneously to treat 1 or more diseases. Studies in the United States showed that, out of 2500 female respondents older than ag 65 years, 23% took 5 or more medications and 12% took more than 10. A study in the United Kingdom determined that 36% of geriatric patients more than 75 years of age used 4 or more prescription medications or nonprescription over-the-counter medications to cure or treat their oral cavity complaints. In 2007 to 2008, more than 88% of Americans older than 60 years took at least 1 prescription medication, 76% used 2 or more prescription medications, and 37% used 5 or more. Other studies suggest that the elderly use 2 to 4 nonprescription medications daily, most commonly nonsteroidal antiinflammatory drugs, antihistamines, antacids (H 2 blockers), laxatives, and sedatives. However, these pharmacologic agents bind to other unwanted potential sites, causing side effects that affect the central nervous system (CNS) and/or the peripheral nervous system. CNS side effects may include confusion/disorientation, hallucinations, sleepiness, clumsiness or unsteadiness, convulsions, and mental status/behavior changes. Peripheral side effects of medications can be salivary hypofunction, difficulty in speech and swallowing, mucous membrane dryness, blurred vision, increased breathing difficulty, difficulty urinating, and constipation. Other problems related to polypharmacy include drug-drug interactions, increased expenses related to not only medications but also hospitalization, as well as adverse events from mistakes in dosing and type of medication given. Dr Mark Beers crafted a set of criteria (Beer criteria) that identify medications that are potentially inappropriate for older adults because of increased risk of adverse events.
As such, the concept of the geriatric syndrome describes an innovative and well-tested approach in managing the interplay between age-related physiologic changes, chronic disease, and functional stressors in the elderly and is now being applied across all health disciplines. Over the last 3 decades, geriatricians have grappled with crafting a universal approach to inform health care educators of the value in training future providers to be competent in treating the elderly based on the complex causes of disease presentation. A recent keynote lecture at the Canadian Geriatrics Society Annual Meeting provided an algorithmic roadmap for the geriatric syndrome using the philosophy of the core competencies represented by the so-called geriatric 5Ms (mind, mobility, medications, multicomplexity, and matters most to me) ( Box 1 ) The health consequences of polypharmacy combined with multimorbidity of disease and their pathologic insults contribute to geriatric syndromes and frailty. The association of frailty and polypharmacy is complex. Frailty is linked to the chronicity of disease (ie, multimorbidity), and this leads to polypharmacy. The relationship is bidirectional because polypharmacy leads to frailty based on the number of drugs administered, weight loss, poor nutrition caused by effects of drugs on oral cavity function, and ultimately the deterioration of health. Other studies have suggested that both frailty and polypharmacy act as modulators for negative effects on health outcomes and that both act independently as risk factors for mortality. The adverse reactions and their toxicities in older people can modify the goals of health care and influence decision making regarding medication delivery.
| Geriatric 5Ms | Focus Areas |
|---|---|
| Mind | Maintaining mental activity Helping manage dementia Helping to treat and prevent delirium Working to evaluate and treat depression |
| Mobility | Maintaining the ability to walk/balance Preventing falls |
| Medications | Reducing polypharmacy Deprescribing Prescribing treatment exactly for an older person’s needs Helping to build awareness of harmful side effects |
| Multicomplexity | Helping older adults manage a variety of health conditions Assessing living conditions when they are affected by age, health, and social concerns |
| Matters most | Coordinating advance care plans Helping manage goals of care Making sure the patient’s goals are reflected in the treatment plan |
With these points in mind, the treatment of oral diseases in the elderly requires a comprehensive approach that combines the multimorbidity of diseases and polypharmacy in order to apply tailored therapeutic intervention for relief of age-related oral health consequences. This article presents a roadmap approach using the concepts of the geriatric syndrome, geriatric 5Ms, and frailty to evaluate symptoms and apply therapeutic strategies in 5 common oral and maxillofacial dysfunctions seen in every day practice. The article applies a comprehensive literature search using the search engines PubMed, Ovid, and Embassy. Publications only in English were chosen over a period of 23 years (1996–2019) using the following search terms: oral health in geriatrics, oral health and elderly, elderly, geriatric health oral health and systemic diseases, oral health related quality of life, polypharmacy, and oral health, and geriatric syndrome. Articles that were chosen also reflected systematic reviews, nonsystematic reviews, and observational and longitudinal studies.
Multimorbidity/polypharmacy/oral and maxillofacial dysfunctions
Oral health is part of overall health and well-being and, as such, requires dental practitioners to navigate through the multimorbidity/polypharmacy/chronic disease landscape in order to treat oral diseases that impede the health of their geriatric patients. The concepts of geriatric syndromes and frailty are applied later in this article to manage 5 common oral and maxillofacial dysfunctions associated with aging. Each oral disease entity is presented with respect to pathologic causation, associated multimorbidity of chronic disease, polypharmacy, and their contribution to these concepts.
Oral and maxillofacial dysfunctions
Xerostomia
Xerostomia (dry mouth) is a major oral health complaint in the elderly. It can be either subjective, based on patient perception with or without diminished salivary flow, or objective, based on measurements of salivary flow. The prevalence rate for dry mouth in the geriatric population can vary from 25% to 30%. There has been much debate about the role of aging on salivary function. Several investigators have supported the premise that aging of the major salivary glands causes a decreased ability to maintain their normal amount of salivary flow. Vissink and colleagues suggested that there is no significant age-related decrease in salivary gland function other than a slight decrease in acini cell number and increase in fatty tissue within the gland. Controversy still exists when the physiologic milieu of the glandular structure is evaluated because alterations in secretory product production at the protein level and other sialochemical electrolytes and immunoglobulins show fluctuations associated with aging. The differences seen among studies may be caused by the type of collection methods used in sampling among patients. There is agreement among all studies that the aging salivary glands, whether they are major or minor, show anatomic changes from secretory to fibrotic independent of the multimorbidity of disease and polypharmacy.
Although several well-designed studies by Ship and colleagues showed that parotid gland function remained stable across the age spectrum in healthy adults, xerostomia/diminished salivary function is a major consideration in the elderly, who frequently have multiple medical problems managed with medications. Diminished salivary function is significantly associated with age-related systemic conditions such as diabetes, autoimmune disease such as Sjögren syndrome, depression, polypharmacy, and other medical interventions such as radiation and chemotherapy for cancer and other tumors. Many classes of drugs used for systemic illnesses have been linked to xerostomia, and the xerogenic effect increases with polypharmacy. Studies equate xerostomia with subjective oral sensorial complaints (OSCs) and polypharmacy. Nagler and Hershkovich characterized relationships among age, drugs, OSCs, and salivary profiles using an age comparison study of healthy patients not hospitalized but living in a community. Patients who were on drugs showed a 50% greater tendency to have OSCs and xerostomia than those who were not on medications, and the total amount of salivary flow was reduced in the elderly compared with younger groups. However, there were no differences in salivary flow rate when small samples of elderly patients on drugs were compared with their age-matched cohorts not on medications. The investigators concluded that there is a decreased rate of salivary flow in the elderly as well as the sialochemical makeup.
Caries Risk and Salivary Hypofunction
Caries is a major oral health problem in the geriatric population because of the alterations of salivary function secondary to polypharmacy and periodontal compromise resulting in gingival recession. Data from the National Institutes of Health, Section on Dental and Craniofacial Research, indicate that 93% of seniors 65 years of age and older have a history of dental caries in their permanent teeth and 18% of seniors 65 years of age and older have untreated caries. Salivary biomolecules and proteins adhere to the tooth surface, establishing a stable protective shield against bacterial seeding and reducing the risk of caries by providing calcium, phosphorus, and fluoride ions, and essential minerals that maintain the highly calcified surface of the tooth. When hypofunction in salivary activity renders a loss of antimicrobial protection, the result may be an increase in cariogenic microorganism colonization. Bacteria in the presence of fermentable carbohydrates become active in the production of acids that both demineralize the tooth surface and create an environment that selects for cariogenic microorganisms. This compromised microenvironment alters the homeostatic demineralization/remineralization cycle, resulting in an increase in caries. The effect is more profound for root caries because cementum and dentin dissolve at a higher pH than enamel.
Treatment strategies: xerostomia and caries risk
Oral health care providers should evaluate patients for any oral and dental complications and then treat as needed based on acute or chronic symptoms. The multimorbidity and polypharmacy of xerostomia require reviewing the patient’s medical and drug histories. After establishing a diagnosis, the clinician can suggest treatment options. All patients with xerostomia should be encouraged to hydrate while eliminating sugar sweeteners in foods and drinks, as well as various other sugar products, because of the increased risk of dental caries. Management of xerostomia is further divided into 2 categories based on the cause of dry mouth.
Local salivary stimulation
The use of salivary substitutes locally in the oral cavity can help reduce the symptoms of xerostomia. Saliva substitutes are carboxymethylcellulose based and often short in relief duration. Various water-soluble lubricants (K-Y Jelly, Taro-Gel, Biotene products) can be applied by foam brush or finger. Although these measures are used with various success rates in many patients, their main disadvantage is limited effectiveness during the night when symptoms are most severe. Sipping water on a frequent basis is a simple solution to providing relief for a dry mouth and is often more palatable to patients. Although salivary replacements may afford some relief, they do not deliver the physiologic constituents that give saliva its essential antimicrobial, lubricating, and demineralizing functions. A more effective strategy is to stimulate the production of saliva when glandular function remains. For instance, sugarless gums are an effective local stimulant because the chewing motion and the flavoring agents increase salivation. Xylitol-based lozenges, sprays, and gum can stimulate the production of saliva, changing the osmotic gradients and improving pH and the buffering capacity. The increase in saliva has the potential to inhibit bacterial growth and metabolism in acidogenic species of Streptococcus . Xylitol can also clear carbohydrate substrates, thereby reducing demineralization and increasing remineralization of hard tissues. Studies have shown a 10% reduction in caries in high-risk populations who are administered xylitol lozenges. Alternative local measures include adhesive discs (eg, Oramoist, OraCoat, XyliMelts) that continuously release xylitol and a flavoring agent to stimulate the production of saliva.
Systemic salivary stimulation
Hypofunction of the major and minor salivary glands caused by polypharmacy is not an issue of physical damage to the salivary gland cells. Studies report that 80% of the widely prescribed medicines cause xerostomia and more than 500 medicines lead to salivary gland dysfunction as a side effect without physical damage but by change in the flow rate of saliva. The long-term use of tricyclic antidepressants, antihistamines, and antiarrhythmic and anticholinergic agents causes a decrease in both flow rate and amount of saliva. Stimulation of saliva can be achieved using pharmacologic interventions. Drugs used to increase salivary flow are termed sialagogues. These medications are effective in increasing salivary secretions and have been shown to decrease xerostomia complaints in patients. Four main drugs are included in this category: pilocarpine, cevimeline, bethanechol chloride, and anethole trithione. There are unwanted side effects of these sialagogues and so the dosages should be titrated up to their maximum amounts and spaced out over 3 months for a full effect ( Box 2 lists the dosing). Use for medication-induced xerostomia may be an off-label use.
| Drug | Dose | Adverse Effects |
|---|---|---|
| Pilocarpine | 3–5 mg 3 times per day | Sweating, nausea, dizziness Pulmonary secretions |
| Cevimeline | 30 mg 3 times per day | Nausea, vomiting, diarrhea Rhinorrhea, sweating |
| Bethanechol chloride | 10–50 mg 3–4 times per day | Miosis, sweating, GI upset |
| Anethole trithione | 25 mg 3 times per day | Flatulence, abdominal pain GI upset |
Caries risk
Loss of saliva enhances the adherence of noxious microorganisms to the tooth surface. The use of supersaturated calcium and phosphate solutions may help to remineralize the hard tissue and decrease the potential for caries. Fluoride salts are bactericidal and contribute to the action of calcium and phosphate in remineralizing the tooth surface. Fluoride varnishes should be considered at least twice per year for patients with high caries risk and 1.1% sodium fluoride can be prescribed for daily use to further enhance remineralization. Most important is the need for judicious follow-up of dental visits every 3 months. A careful evaluation of new caries and any soft tissue changes is paramount to assess new-onset inflammation and infection, as well as to monitor any changes caused by new or existing medication regimens.
Periodontal disease
Periodontitis and multimorbidity of disease
Periodontal disease is among the most prevalent oral manifestation seen in the geriatric dentate population both nationally and globally. Studies have proposed that periodontitis in the elderly may not be considered a specific disease entity but a result of age-related changes in the periodontium caused by the length of time periodontal tissues are susceptible to bacterial exposure along with specific health problems of aging individuals. Epidemiologic studies have shown that accumulation of plaque and consequent gingivitis/periodontitis become more severe as the patient ages (1.8% increasing to 3.3% after age 65 years). With aging, the anatomy changes; gingiva and periodontal ligaments are weakened by decreased collagen. Atherosclerosis develops in alveolar bone and the vasculature of the ligaments becomes dysfunctional. The result is gingival recession and increase in crown length of the teeth with a subsequent risk of caries formation in the cementum exposed to the oral cavity. With aging, gingival epithelium becomes thinner and keratin tissue increases. In addition, increase is reported in the cellular density.
At the biological level, changes in structure and function during aging can affect the host responses to the microorganisms responsible for plaque, and, as such, influence the rate of destruction of the periodontium. Alterations in inflammatory cascades (discussed later) as a result of periodontal disease can then precipitate/exacerbate chronic diseases such as diabetes and cardiovascular disease (CVD) in the elderly. Pena and colleagues (2017) suggest that interaction of microbiota and aging of the immune system and motor systems contribute to exacerbation of chronic disease in the geriatric population. Over the past 2 decades, there has been a strong interest in the bidirectional relationship suggested earlier between systemic diseases and periodontitis in the geriatric population. The bidirectionality is expressed through systemic disease that predisposes a person to periodontal disease. This periodontal-systemic connection is influenced by inflammatory mediators (interleukin-6; C-reactive protein), as well as endocrine deficiencies in insulin growth factor and dehydroepiandrosterone. The resultant compromised immune system provides a breeding ground for infectious and opportunistic microbes that precipitate and exacerbate the chronic illnesses and chronic periodontitis that burden the elderly.
Epidemiologic studies support valid evidence that periodontitis increases the risk of diabetes and CVD, both of which can serve as significant risk predictors for frailty. Studies have shown that cohorts with diabetes mellitus are 2.8 times more likely to have periodontal disease and 4.2 times more likely to have alveolar bone loss compared with controls matched for age and sex. Cronin concluded that periodontal disease was a risk factor for CVD as well as osteoporosis among a community of older adults enrolled in a clinical trial over a 5-year period. The data also suggested that ethnicity was a significant risk predictor for osteoporosis and concomitant decline in periodontal status; it was greater in white people compared with African Americans. Gender differences were also found and several studies suggested that CVD in women is not as significant as that seen in their male cohorts because of the effect of osteoporosis on dental disease (ie, less periodontitis because of earlier extractions and less caries). As such, women may not reach the threshold of periodontal disease necessary for the vascular consequences and myocardial breakdown compared with their male cohorts. Further studies are needed with larger cohorts to support this hypothesis.
Recent studies have focused on the relationship of periodontitis as a predisposing factor in dementia and Alzheimer disease. This focus is not surprising because other studies have correlated the onset of neurodegenerative diseases with alterations in the ratio of several inflammatory mediators associated with periodontal disease, including C-reactive protein, tumor necrosis factors, and matrix metalloproteases. Kamer and colleagues suggested that oral diseases that alter inflammatory cascades influence the development or progression of Alzheimer disease and dementia by local and systemic inflammation that travel to the brain and cause vascular damage with subsequent neurodegeneration. Chronic periodontitis and periapical lesions may also cause low-grade inflammation that can spread into the brain and secondarily provide a path for bacteria to penetrate the blood-brain barrier. Causative bacteria for oral diseases, such as Treponema denticola , Porphyromonas gingivalis , and Streptococcus mutans , seem to have neuroinvasive properties. Tiisanoja and colleagues concluded that systemic inflammation can exert a burden on the CNS that may have the potential to alter cognitive function. Oral hygiene and good oral health may decrease the inflammatory burden, concomitant bacteremia, and susceptibility to dental caries, which may have the potential to prevent dementia and Alzheimer symptoms. A complex balance of cofounding factors, such as biologically cognitive, psychological, and social interactions, may be significant contributors as well. However, interventional trials are still needed to support whether the so-called periosystemic connection precipitates/exacerbates dementia/Alzheimer disease, as well as other neurodegenerative disease sequelae. Further studies are needed to correlate mechanisms of altered inflammatory cascades in oral diseases and the development of neurodegenerative disorders.
Periodontitis and polypharmacy
The impact of polypharmacy on periodontal disease according to Ciancio can be separated into 4 main categories: (1) those affecting oral hygiene; (2) those affecting the ability to diagnose periodontitis; (3) those that affect gingival and oral mucosa; and (4)those affecting the alveolar bone. In addition, the adverse effects of polypharmacy go beyond medicinal to include increased medical expenses, increased hospitalization, and mistakes in dosing of medicines in the elderly by the health care provider. Systemic illnesses being treated with polypharmacy can result in oral manifestations such as xerostomia and concomitant salivary gland dysfunction, the latter affecting periodontal health. Groups of medications predisposing patients to xerostomia include cardiovascular (antihypertensive diuretics, angiotensin-converting enzyme inhibitors, and calcium channel blockers), antidepressants, anti-Parkinson medications, and antiallergy medications. The effect of xerostomia predisposes pathologic invasion of bacteria and the excess plaque biofilm can cause caries, especially on root surfaces.
Medicinal agents such as ginger, fish oil, garlic, and ginseng can confound the diagnosis of gingivitis and periodontitis caused by anticoagulants, antiplatelet medications, nonsteroidal antiinflammatory drugs, aspirin, and herbal compounds. Each can contribute to confusion with respect to causes of bleeding during the periodontal examination. Diseases of the oral mucosa, such as aphthous ulcers and lichenoid lesions, are often caused by antibiotics, antiseizure medications, and antipsychotic medications, which are often prescribed to the geriatric population. Other studies suggest that multiple medication regimens in elderly patients have the potential to affect clinical attachment levels and pocket depth. The oral manifestations discussed earlier can impair health-related quality of life because of poor stability and mobility of removable prosthetic appliances causing speech and nutritional impairment. Natto and colleagues suggest that clinical attachment level in the elderly may be associated with greater than 5 medications that are taken for chronic diseases, whereas other medications may decrease the risk of periodontal breakdown.
The effect of polypharmacy on alveolar bone is a topic that has gained much interest recently with the changes in treatment of osteoporosis and cancer therapies that are prolonging patients’ lives. Medication-related osteonecrosis of the jaw, although an uncommon disease, is often of concern in patients who are exposed to bisphosphonates, antiresorptive medications, and antiangiogenic medications. Future studies are underway to discriminate whether drug combinations in varying numbers precipitate breakdown in the health of the geriatric periodontium (discussed later).
Treatment strategies: periodontal disease
Oral hygiene in frail individuals, although poor, can be improved using an educational program or oral hygiene protocols administered by family members and skilled dental auxiliary/facility staff. A systematic review by Shanbhag and colleagues (2012) suggests that nonsurgical debridement in the treatment of periodontitis provides moderate improvement in health-related quality of life among the elderly. One of the major challenges for preventive care is to develop a plan for monitoring periodontal care because the basis for prevention is to diagnose disease at its earliest stages. Components for preventive strategies in the elderly with respect to periodontal disease are discussed next.
Plaque removal
Mechanical plaque removal is a well-tested approach to decrease gingival inflammation and caries risk. Plaque retention in the elderly is often caused by gingival recession with root caries and large dental restorations. Poor diet also contributes to increased inflammation and concomitant gingival recession. The use of a soft tooth brush and the Bass technique allows minimal tooth abrasion. Patients with compromised manual dexterity from chronic diseases can be instructed with rotary brushing and specially designed toothbrushes that are easy to manipulate. Handles have been developed that are larger and easier to grasp if the handle of a regular toothbrush cannot be used.
Mouth rinses
The use of oral antimicrobial rinses is not new to oral health care. Okuda and colleagues reviewed the use of Listerine as an antimicrobial that killed microbes in 30 seconds, many of which are significantly virulent (ie, S mutans , Actinomyces viscosus, Staphylococcus aureus , Candida albicans , Prevotella intermedia , and P gingivalis ). There are an increasing number of elderly and medically compromised hosts who are potentially at risk for developing pneumonia because of silent aspiration of microbes in the oral cavity. As such, antimicrobial mouth rinse may be effective in preventing dental plaque accumulation when used in addition to the mechanical control of plaque, because these patients tend to have difficulty in brushing teeth by themselves. The use of antimicrobial mouth rinse therefore has the potential to not only prevent bacterial pneumonia but also in improve patients’ quality of life by preserving their oral health. Chlorhexidine rinses have been well accepted for periodontal care and the treatment of plaque in the elderly. The variety of therapeutic rinses now available are still beneficial to the hard and soft oral tissues, especially in the reduction of candidiasis and mucositis in patients who are undergoing chemotherapy.
Tobacco use
Numerous studies have supported the premise that smoking is a major factor associated with accelerated periodontal destruction. Debate continues as to whether the progressive loss of periodontal support in later life is caused by excessive tobacco smoking in youth. Several longitudinal studies suggest that 30 pack years is required to show an increased risk for severe periodontitis; however, several other risk predictors are required, such as low socioeconomic status, ethnic variation, and lack of regular visits to a dentist. Other studies characterize a genetic link based on single nucleotide polymorphisms (SNPs) and smoking based on specific combinations of SNPs that must be present. Studies are still underway and future directions include number of years of tobacco exposure, better genetic mapping, access to dental care, and coping mechanisms for stress.
Periodontal health and dental implants
Systemic diseases, polypharmacy, and oral health imbalance can impede both the success of implant placement as well as their longevity. When older adults are compared with younger cohorts, implant survival seems constant over at least 3 to 5 years. However, bone loss over time seems significant in older patients. A systematic review by Al-Fahd concluded that dental implants in edentulous elderly patients are a predictable treatment option with minimal complications. However, practitioners must be cautious in their choice of patients because increased age is associated with increased risk for chronic disease. The latter can compromise the quantity and quality of bone and soft tissue required for implant survival and success. Further studies using randomized controlled trials and larger sample sizes are now underway to allow better prospective outcomes with respect to implant placement in the elderly.
Although the literature with respect to periodontal therapy in the geriatric population is still under scrutiny, some consistencies remain. Gingival recession is a fact of aging and may be a sequela of periodontal pocketing earlier in life. An oral and maxillofacial geriatric syndrome is manifested by chronic illnesses and polypharmacy that impedes the periodontium’s ability to heal. Significant challenges remain from the patients’ perspective of oral maintenance and access to care. The practitioners’ expectations for good oral hygiene depend on understanding how systemic diseases and their management affect the progression of periodontal disease.
Disorders in taste
Loss of taste in the geriatric population may result from physiologic changes in the cells initiating taste perception, a declining olfactory function, poor nutrition, certain diseases, medications, and inadequate dentition. Alteration in the patient’s perception of taste can significantly impede appetite, healthy food choices, and health-related quality of life. Research has focused on food preferences and healthy nutrition in the elderly because of their declining perception of salty, bitter, and sour taste. Studies in the detection and recognition of threshold levels of the 4 commonly tested tastes (sweet, salty, bitter, and sour) show modest age-related changes in healthy older people who take no medications. However, older adult cohorts with at least 1 medical condition and taking medications show a significant decline in taste perception. As a whole, the preference seems to be for foods deficient in calcium, magnesium, iron, vitamin D, vitamin B 6 , thiamin, retinol, and folic acid. These deficiencies lend themselves to a subsequent shift to more unhealthy food choices and an increased risk of diet-related diseases such as obesity, cardiovascular dysfunction, and metabolic dysfunction, all of which potentiate adverse oral health in these patients.
Dysgeusia (altered sense of taste) is most often seen in the elderly as a result of chronic disease and polypharmacy, as well as the physiologic, psychosocial, and emotional stress that contribute to poor nutrition. Dysgeusia is further potentiated by habits such as tobacco and alcohol use, both of which cause an alteration in salivary flow, with the resulting xerostomia potentially contributing to BMS and further loss of appetite (discussed elsewhere in relation to BMS). Toffannello and colleagues compared loss of taste preferences in a cohort of hospitalized patients with the risk predictors of multimorbidity and polypharmacy with a healthy cohort matched for age. The ability to differentiate sour taste was significantly lower in hospitalized patients, as well as thresholds of sweet, bitter, and salty at diluted concentrations compared with other cohorts. The investigators concluded that elderly patients who are hospitalized and malnourished benefit from flavor-enhanced foods to increase their caloric intake and improve their health.
Treatment strategies: taste disorders
The aging of the gustatory apparatus, as discussed earlier, and the multimorbidity of disease and its management with multiple medications become causative in clinical presentations of altered taste, loss of taste, metallic taste, and poor nutritional intake. As such, taste disorders are representative of an oral and maxillofacial geriatric syndrome. Taste disorders contribute to a vicious cycle of altered intake and a compromised nutritional status, which may in turn lead to further weakness and poor health outcomes contributing to frailty. Establishing treatment strategies to combat taste disorders in the elderly can therefore be challenging because of not only the multimorbidity of disease but also the polypharmacy administered. The latter contributes to a cascade of not only gustatory dysfunction but also weight loss, anorexia, muscle wasting, and malnutrition. Studies agree that although the need for medication is essential to combat systemic disease, taste perception can be reprogrammed so that the risk of malnutrition is reduced. Toffannello and colleagues, in a cohort study, found that food choices, especially flavor-enhanced diets using artificial sweetener and monosodium glutamate, increased the elderly’s perception of taste and diet preferences, increased salivary flow, increased grip strength, and decreased oral complaints. Future studies are underway to determine the relationship, if any, among physiologic, social, and psychological factors in the elderly’s perception of taste and diet food choices.
Mastication/swallowing
Masticatory and swallowing disorders in the geriatric population are prevalent and together can be detrimental to everyday health and well-being. As patients age, mastication and swallowing serve as significant risk predictors for poor oral health and malnutrition. In addition, loss of teeth can serve as a good mortality predictor of elderly life impairment because of its direct influence on mastication and swallowing. Prosthetic replacement of teeth can lead to adverse masticatory function if conditions such as palatal stomatitis or traumatic ulcers develop, and the outcome is worsened in the presence of poor oral hygiene and increased tobacco and alcohol use. In addition, the physiologic aging of mastication can be affected by socioeconomic status, degree of dependence on family support, and general state of health. Chewing difficulties are more prevalent because of poor dentition, concomitant ill-fitting oral prostheses, and the increased incidence of chronic illnesses and neurodegenerative diseases that impede CNS control of gustatory function. Several studies have correlated tooth number with masticatory success in the elderly. In patients with fewer than 21 teeth, there is a substantial alteration in choice of diet: a decrease in protein and an increase in carbohydrates and micronutrient consumption even if prosthetic rehabilitation is attempted.
Dysphagia (disorders in swallowing) in the elderly is often associated with multimorbidity and polypharmacy, lack of saliva, and poor masticatory function, and can be considered as a geriatric syndrome. Neuronal networks in the aging brain break down because of age-related physiologic changes associated with the biomechanics of swallowing, caused by neurologic diseases, gastrointestinal dysfunction, and/or tumors. Various CNS illnesses, including Alzheimer disease, schizophrenia, and Parkinson disease, can contribute to a dyskinesia/dystonia of the musculature. Although there is no absolute prevalence rate for swallowing disorders, reported rates vary based on the anatomic location and type or stage of swallowing disorder (ie, oral, oropharyngeal, and esophageal). The prevalence rate of oromandibular dystonia ranges from 0.52 to 30 per 100,000 in elderly patients based on meta-analyses. Box 3 lists causes of dysphagia in the elderly.
