‘Doctor, I am 75 years old and you ask me to go see a dentist? I have never seen one ’.
This quote is laden with a lot of information including myths about oral health and the older person. The objective of writing this article is to raise awareness about the requirements and need for optimal oral health with ageing. Mr. A.K, who made the statement above, exhibited “ageism”, prejudice on account of age! The statement has shown the gap in healthcare provision, lacking comprehensiveness. If in 75 years he never was consulted by a dentist, it means he was never referred, and not counseled to see one. It also suggests that oral health is not prioritized.
Ageing in itself while not a disease is a big risk factor for the existence of multiple chronic medical conditions, a situation described as multi-morbidity. Older persons with multi-morbidity, who have 2 or more chronic medical conditions, are at great risk of frailty, disability, and mortality when not managed promptly and appropriately.
The common conditions that we see in older persons with multi-morbidity include Hypertension, Diabetes Mellitus, and Joint diseases (degenerative and age-related). The other conditions are visual challenges (Cataracts, Glaucoma) and hearing issues (age-related sensorineural hearing loss). Multi-morbidity and its consequent complications such as Stroke, falls and mobility challenges, blindness, and hearing impairment impact the quality of life of older persons and increase dependency with the risk of elder abuse. The stated disabilities/ complications of multi-morbidity are well documented and recognized but one disability that is overlooked is that of natural tooth loss.
Natural tooth loss is contributed to by ageing and it impacts wellbeing- reduced masticatory capacity and distortion of the facial silhouette. The reduced mastication impairs feeding leading to a greater risk of malnutrition. The human tooth plays multiple other roles outside of helping us to chew our food and allow proper digestion. Our teeth contribute to the maintenance of the shape of the lower part of the face, they get uncovered when we give a wide and beautiful smile to those we encounter. So a mouth full of teeth that are in place gives confidence to humans to smile broadly and freely.
When teeth are lost through surgical extraction for disease or from trauma, the capacity to give a wide brimming smile is lost, and the face contour changes. When these happen, older persons lose self-confidence, develop anxiety and even start isolating themselves. Research has shown that social isolation contributes to mood disorders such as depression and generalized anxiety which lead to poor health outcomes. Those who suffer mood disorders tend to be less likely to comply with prescription drugs for existing medical conditions with consequent advancement in the disease process.
It is important that oral health is a part and parcel of the integrated care provided to older persons. Also imperative is a life course approach to oral health as exists in the developed world. The dentist sometimes identifies subtle cognitive changes that suggest dementia in a longstanding client. From childhood, routine dental care is provided- health promotive care, and interventions for preserving natural teeth for as long as possible, as people get older. Lifestyle practices that preserve natural teeth include the use of appropriate dental brush bristle character, appropriate brushing technique, and frequency, and avoidance of tobacco use. Certain chronic medical conditions do affect the health of our teeth. These include poorly managed Diabetes Mellitus (DM), which escalates the risk for a condition called periodontitis.
Advancing age also up-surges the risk for this condition. Receding gums are common in older adults. This is when the gum tissue pulls away from the tooth, exposing the base, or root, of the tooth. This makes it easy for bacteria to build up and cause inflammation and decay (periodontal disease). So persons with DM while ageing have an accelerated risk of periodontitis. A lifetime of brushing too hard can also cause gums to recede. Gingivitis is an early type of gum disease. It occurs when plaque and tartar build-up, irritate, and inflame the gums.
Older persons are also at increased risk of dry mouth which can also be caused by certain medications used for treating medical conditions such as hypertension, prostate enlargement, and depression. When the mouth is dry, it allows bacteria overgrowth that can further increase the risk for periodontal disease. Periodontal disease weakens the base of the tooth, causing tooth loss. Older persons are also at risk of oral cancers, an uncommon cause of tooth loss but can shorten life. The cancers can be detected early through routine oral health checks during a visit to the dental clinic.
Recommendations for a life course approach to ensuring good oral health and avoiding the disability of Tooth loss
- Use appropriate dental brush (soft bristle) and appropriate technique
- Brush the teeth twice daily and in between after meals (to reduce food debris and bacteria load)
- Visit the dental clinic twice a year for scaling and polishing (more in-depth cleaning to remove debris from in between the teeth & reduce bacteria load)
- Avoid tobacco use
- Treat medical conditions such as DM appropriately
- Visit the dentist annually for routine oral health examination regardless of your age
- General practitioners should make a point to refer patients for annual dental review regardless of age
- When teeth are lost to be replaced to sustain chewing capacity and ensure good nutritional status
- Use mouth freshener if you have dry mouth to ensure freshness of breadth (intermittently sweep your tongue through the mouth to moisten the mouth if you have not had cause to speak for a length of time)
- Drink adequate amount of water daily and more during the dry and hot season to keep the mouth hydrated
- Health insurance coverage should include oral health to reduce out of pocket expenditure and enhance dental care seeking behavior
- Oral health to be incorporated into services provided at the primary health care level
Dr. Ogugua Osi-Ogbu MD FWACP (Int med) AGSF
Consultant Physician/ Geriatrician, Head Geriatrics Unit, Department of Internal medicine, National Hospital Abuja.