Oral health not only refers to the absence of dental diseases but its contribution to general well-being and quality of life (QoL), which is more difficult to achieve with advancing age (Lamster and Northridge, 2008).
Learning about the characteristics of this population can give helpful insights into oral health care for the elderly and how to modify approaches to suit individual needs.
Demography of Aging: Australia and New Zealand
Due to medical advances, socioeconomic development and improved public health measures, the average lifespan has improved, and mortality/fertility rates have reduced. In New Zealand (NZ) the number of people aged 65+ doubled between 1991 and 2020, to reach 790,000. This number is projected to double again by 2056 with a significant increase in the 85+ age group, which will be approximately 320,000 in 2048 (Stats NZ, 2021). In Australia, from 1999 to 2019, the population of those aged 65+, increased from 12.3% to 15.9%, with a 2.5% increase in the age group 85+ in the same period (Australian Bureau of Statistics, 2019).
The New Zealand 2018 census results show that the changing demography consists of a more diverse cultural makeup (Statistics NZ, 2021). Furthermore, poor oral health statistics are represented disproportionally in both countries by the indigenous population and minority groups. Collectively, these statistics highlight the burden on oral health services because more people are living longer and are more likely to retain natural teeth. However, the elderly population is made up of distinct groups and this can affect the way a treatment plan is formulated. Below are the estimated age groups and their different characteristics:
- 65-74 are considered as young elderly who are relatively healthy and active
- 75-84 are mid-elderly who could vary from being healthy and active to being dependent with chronic diseases
- 85+ are the frail group with one or more medical conditions
(Razak, Jose Richard, Thankachan, Abdul Hafiz, Nanda Kumar, Sameer, 2014).
Senior Living Spectrum
All elderly are not subject to the same living circumstances. We must appreciate the wide spectrum of senior living and levels of senior care (National Caregivers Library, 2019). At one end of the spectrum are individuals who are more independent, perhaps requiring some form of home assistance, but who are able to carry out dental homecare themselves. Even so, there may be opportunities for oral health practitioners to make suggestions for an improved homecare routine with a focus on preventative strategies.
On the other end of the spectrum individuals may live in aged-care facilities in which healthcare assistants and/or nurses provide the necessary care. Moreover, in institutionalised facilities care resistant behaviours may be more common and add further complications. Evidence reveals that institutionalised individuals are at greater risk of developing dental diseases than the non-institutionalised, as reported in a study of several rest homes in Adelaide in 2005 (Lamster and Northridge, 2008).
Determinants of Oral Health in Elderly
Treating the elderly population poses many challenges for oral health professionals especially when implementing preventative strategies. Clinicians have to consider deterioration of physical and mental health, medical condition(s) and polypharmacy when managing this cohort. The elderly population is a unique group of vulnerable individuals who become the main consumers of primary health care services and are more likely to access multiple services such as medical clinics, outpatient hospital services, pharmacies, dental care and supportive care (Lamster and Northridge, 2008).
Oral health practitioners in collaboration with allied health services can achieve better oral health outcomes and continuation of care.
With individuals keeping their natural teeth further into life there is a greater need for support, preventative dental treatment and restorative work. The oral-health concerns during ageing can include one or more of the following:
- Reduced chewing efficiency
- Poor nutritional status
- Denture-related issues - such as ill fitting, damaged/cracked dentures
- Edentulism or tooth loss
- Reduced sensitivity to pain
- Tooth Sensitivity
- Reduced salivary function or xerostomia
- Changes in teeth such as erosion, attrition and recession
- Changes in oral mucosa - less regenerative capacity
- Coronal Dental caries - higher rate
- Root caries - higher rate
- Periodontal disease - more prevalent
- Oral cancer
- Complications by comorbid conditions such as hypertension, heart disease, cancer and diabetes mellitus
- Age-related physiologic changes
(Razak et al., 2014; Gil-Montoya, Ferreira de Melli, Barrios, Gonzalez-Moles, Bravo, 2015)
Other factors that can affect oral health in the elderly are barriers to accessing dental care resulting in irregular dental visits due to cultural views, ethnic background, inability to travel, fear and anxiety, and financial strain.
Recommendations for oral health interventions and other suggestions
- Diet and nutrition counselling should be considered as an integral part of the oral health assessment. Refer to GP, nutritionist or dietician if necessary
- Toothbrushing: Use an electric toothbrush with an ergonomic handle. This makes it easier to grip and move around. Alternatively, the way you hold a toothbrush can be changed (refer to resource below) as well as the shape and size of the handle to suit individual needs. Soft or extra soft bristled toothbrushes with bass or modified bass brushing technique using light pressure are best
- Mouth rinses: either fluoride rinses or chlorhexidine rinses can help control plaque and prevent decay important for those with physical or mental disability. A small bottle spray can help if the individual is unable to swish around the liquid
- Adaptive dental aids: special handles for floss, toothbrush, or interdental aids
- Water flossing - not a replacement to flossing but helps those with reduced dexterity
- Use high fluoride toothpaste
- Apply fluoride varnish regularly
- Communicate: Keep oral health instructions simple, use easy to understand language and visual aids. Speak at a volume they can hear clearly but not raising your voice
- Counsel and educate caregivers or families to support with homecare
- Provide denture care instructions
- Use tell-show-do method
- Employ preventative counselling
- Make referrals to other health care professionals as required
- Work with allied health professionals
(Razak et al., 2014; Lamster and Northridge, 2008)
Christine Murthi
Christine Murthi is an Oral Health Therapist based in New Zealand. She is currently studying a Masters in Health Science at Auckland University of Technology. Prior to this she had secondary teaching/tutoring experience spanning more than ten years.
Through this teaching experience combined with her diverse cultural background she has developed a passion for promoting diversity in clinical practice, overcoming communication barriers and connecting with the community. As a member of the Colgate Advocates for Oral Health: Content Community, her contributions to the dental community aim to promote good oral health for all and keeping a healthy smile for life.
Article Published in Dental Solutions Feb-March 2024
Resources
1. Modifying toothbrush: https://www.mytoothbetold.com/modify-toothbrush-arthritis/
2. Better oral health in residential care - A toolkit: https://www.sahealth.sa.gov.au/wps/wcm/connect/77fd7a004b3323958834ad e79043faf0 BOHRC_Professional_Portfolio_Full_Version%5B1%5D.pdf?MOD=AJPERES&CACHEID=ROOTWORKSPACE77fd7a004b3323958834ade79043faf0-nKKIuxl
Australian Bureau of Statistics. (2019). Australian Demographic Statistics: Twenty years of population change. Retrieved September, 2021, from https://www.abs.gov.au/ausstats/abs@.nsf/0/1cd2b1952afc5e7aca257298000f2e76.
Gil-Montoya, J. A., Ferreira de Melli, A. L., Barrios, R., Gonzalez-Moles, M. A., & Bravo, M. (2015). Oral health in the elderly patient and its impact on general well-being: A nonsystematic review. Clinical Interventions in Aging,10, 461–467.
Lamster, I. B., & Northridge, M. E. (2008). Improving oral health for the elderly: An interdisciplinary approach. Springer Science + Business Media. Lauritano, D., Moreo, G., Della Vella, F., Stasio, D., Carinci, F., Lucchese, A., & Petruzzi, M. (2019) Oral Health status and need for oral care in an aging population: A systematic review. International Journal of Environmental Research and Public Health, 16(22), 4558. https://doi.org/10.3390/ijerph16224558
National Caregivers Library. (2019).The long-term care spectrum. Retrieved September, 2021, from http://www. caregiverslibrary.org/Caregivers-Resources/GRP-Care-Facilities/The-Long-Term-Care-Spectrum-Article
Razak, P. A., Jose Richard, K. M., Thankachan, R. P., Abdul Hafiz, K. A., Nanda Kumar, K., Sameer, K. M. (2014). Geriatric oral health: A review article. Journal of International Oral Health, 6(6),110-116.
Stats NZ (2021). National population projections: 2020(base)–2073. Retrieved September, 2021, from https:// www.stats.govt.nz/information-releases/national-population-projections-2020base2073