Burden of Oral Disease Among Older Adults and Implications for Public Health Priorities

Susan O. Griffin, PhD; Judith A. Jones, DDS, MPH, DScD; Diane Brunson, RDH, MPH; Paul M. Griffin, PhD; William D. Bailey, DDS, MPH

Disclosures

Am J Public Health. 2012;102(3):411-418. 

In This Article

Poor Oral Health and Quality of Life and General Health

Poor oral health can limit food choices and diminish the pleasures of eating.[1] Studies indicate that extensive tooth loss impairs chewing efficiency.[3,4] Because having 20 teeth is considered necessary for functional dentition[5] and chewing with removable dentures is at least 30% to 40% less efficient than chewing with natural teeth,[6] persons with extensive or complete tooth loss are more likely to substitute easier-tochew foods such as those rich in saturated fats and cholesterol for foods high in carotenes, vitamin C, and "ber.[7,8] Among older persons, tooth loss has been shown to be associated with both weight loss[9] and obesity.[10]

Extensive and complete tooth loss may also restrict social contact and inhibit intimacy.[1] Tooth loss can affect speech, which in turn limits social interaction,[11] detracts from physical appearance,[12] and lowers self-esteem.[13]

Untreated oral diseases will not resolve if left untreated and can profoundly impact quality of life. Pain from untreated oral diseases can restrict normal activities of daily life and disturb sleep.[1] In advanced states, caries involves the pulp of the tooth and destroy tooth structure leaving only root fragments that can lead to ulcerations and abscesses.[14] Periodontitis can destroy the supporting tissues of the teeth and also lead to abscesses that result in swelling, bleeding, and pain.[15] Untreated, caries and periodontitis ultimately lead to tooth loss.[16]

Failure to prevent or control the progression of oral disease may increase the risk of adverse health outcomes. A recent Cochrane systematic review found evidence that the treatment of periodontal disease improved metabolic control among persons with type 2 diabetes.[17] Another recent study found that invasive dental procedures (periodontal therapy and tooth extraction), likely avoidable with early treatment and prevention, increased the incidence of ischemic stroke and myocardial infarctions.[18]

Studies have demonstrated a similar association between oral hygiene and positive health outcomes. Two systematic reviews[19,20] found that enhanced oral hygiene care can prevent respiratory infections and death from pneumonia in elderly people in hospitals and nursing homes. Another recent study found that frequent toothbrushing was associated with lower levels of cardiovascular disease.[21]

Preventing Poor Oral Health

Poor oral health is largely preventable.[1] A meta-analysis found that fiuorides, whether self-applied (i.e., toothpaste), professionally applied, or delivered through community water systems, reduce coronal caries incidence in adults by about 25%.[22] Fluorides[22] and antimicrobial varnish (i.e., chlorhexidine-thymol)[23] are also effective in reducing root caries incidence. Effective interventions to prevent and control periodontal disease include scaling and root planing[24] and oral health education on self-care.[25] Increased exposure to fiuorides has been a major factor contributing to the decline in edentulism (i.e., total tooth loss) over the past 50 years.[26] By 2004, the prevalence of complete tooth loss among those aged 75 years and older had dropped to less than half the 1957 rate—68% versus 31%.[16,27]

Untreated Dental Disease and Limited Access to Care

The presence of extensive tooth loss, untreated caries, and untreated periodontal disease among older adults[27] indicates that a sizable number may not have access to interventions effective in preventing and controlling oral disease. In 2008, almost half of older community-dwelling dentate adults reported no past-year dental visit.[28] There is also evidence that those in highest need are the least likely to receive care. Among dentate adults aged 65 years and older, racial/ethnic minorities were about half as likely to report a past-year dental visit[28] and about twice as likely to have at least 1 tooth with a cavity in need of a restoration than were their nonminority counterparts—37% and 41%, respectively, for non- Hispanic Blacks and Mexican Americans versus 16% for non- Hispanic Whites.[27]

Older adults may have more difficulty accessing effective interventions to prevent and control oral disease than do younger adults. One major barrier is lack of insurance. Medicare only covers narrowly de"ned medically necessary procedures and many state Medicaid programs do not cover dental services for adults. This results in adults paying an increasing portion of their dental expenditures out of pocket as they age. National data indicate that the percentage of dental expenditures paid by private dental insurance decreased with age from 50% for dentate persons aged 55 to 64 years, to 22% for dentate persons aged 65 to 74 years, and to 14% for dentate persons aged 75 years and older.[28] This lack of dental insurance coverage may affect treatment choices. Mean dental expenditures were lower among persons aged 75 years and older compared with persons aged 55 to 74 years,[29] suggesting that these persons may have selected no treatment or lower cost options such as tooth extraction instead of more expensive endodontic and prosthetic treatment.

As older adults age they may experience difficulties brushing their teeth, which has been shown to be effective in preventing oral disease,[30] and in seeking effective clinical care.[29] For example, institutionalized and homebound elderly for whom self-care may be especially difficult have poorer oral health than active elderly.[31–33]

Low utilization of dental care may also be attributable to lack of perceived need. Among adults with similar clinical dental health status, older adults report less need for dental care than do younger adults. Perceived need is an important predictor of dental utilization—a multivariate analysis found the best predictor of dental utilization by older adults to be perceived importance of dental care followed by perceived need and number of teeth remaining.[34] The disadvantaged and ethnic minorities are also more likely to report lower perceived need than other older adults with similar clinical status.

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