Australian Dental Journal
The official journal of the Australian Dental Association
Australian Dental Journal 2015; 60:(1 Suppl): 86–94 doi: 10.1111/adj.12287
Ageing, dementia and oral health P Foltyn* *Dental Department, St Vincent’s Hospital, Darlinghurst, New South Wales, Australia.
ABSTRACT Neurocognitive decline and delirium, frailty, incontinence, falls, hearing and vision impairment, medication compliance and pharmacokinetics, skin breakdown, impaired sleep and rest are regarded as geriatric giants by gerontologists, geriatricians and nursing home staff. As these are all interrelated in the elderly, failure to act on one can impact on the others. However, the implications of poor oral health have for too long been ignored and deserve equal status. Mouth pain can be devastating for the elderly, compound psychosocial problems, frustrate carers and nursing home staff and disrupt family dynamics. As appearance, function and comfort suffer, so may a person’s self-esteem and confidence. The contributing factors for poor oral health such as rapid dental decay, acute and chronic periodontal infections and compromised systemic health on a background of a dry mouth, coupled with xerostomia-inducing medications, reduced fine motor function, declining cognition and motivation will not only lead to an increase in both morbidity and mortality but also impact on quality of life. Keywords: Elderly, frail, geriatric, gerontology, oral health. Abbreviations and acronyms: ABS = Australian Bureau of Statistics; CT = computed tomography; OPG = orthopantomograph; RACF = residential aged care facility.
AGEING Ageing is a natural biological process which is primarily influenced by our genetic makeup. However, in recent centuries it has become more heavily influenced by social, environmental, economic and medical changes as well as physical and mental health. In 19th century Britain being over 50 was regarded as old whereas in Australia a new pensionable age of 70 was proposed in the 2014 Federal budget. In the 1950s Australia had a high level of prosperity and enjoyed the benefits of being dubbed the ‘lucky country’. However, like many aspects of health care dentistry had not progressed far beyond amalgam fillings and extractions over the previous decades. If you were in your late 60s in the early 1950s you would have been considered old. Many ‘old’ people then had no natural teeth and dental care was about extractions and getting a good set of dentures. In those days some rural women were sent to the dentist to have all their teeth removed so that they wouldn’t be a burden on their future husbands. As a result of better oral health education and many parts of Australia adopting water fluoridation in the 1960s, we now find many 50-year-olds who had access to fluoridated water in their formative years 86
have had a negligible number of carious lesions and many 80- and 90-year-olds have a functional dentition. Sadly over recent years, an increased consumption of sugared drinks and snack foods has seen increased caries rates in today’s youth. The Australian Bureau of Statistics (ABS) produces Life Tables1 every two years which reveal that the average 85-year-old male now lives for a further 6.1 years whilst the average 85-year-old female a further 7.1 years. These figures have fluctuated over successive reporting periods but are generally on a gradual increase, which means that the average 85year-old in 20 years’ time could expect to live well into their 90s. Although increasing rates of diabetes and obesity may slow these figures down, they are countered by decreasing levels of smoking. 2010 was a landmark year as the first of the postWorld War II baby boomers turned 65. Baby boomers are the bulge in Australia’s and most of the western world’s demographic profile. The next decade will see a greater acceleration of the many medical, social, communal and economic impacts of ageing and dementia than previously seen in Australia’s history. If our youth survive childhood illnesses, cures or better treatment regimes are developed for some of the common cancers, smoking rates are reduced further, © 2015 Australian Dental Association
Ageing, dementia and oral health they don’t binge drink and overeat, exercise even moderately and don’t drive motor vehicles at excessive speeds, most children born today will reach 100 years of age. DEMENTIA Dementia2 describes a collection of symptoms caused by disorders affecting the brain. It is not one specific disease. Dementia affects thinking, behaviour and the ability to perform everyday tasks. Brain function is affected enough to interfere with the person’s normal social or working life. Dementia can occur at any age; however, it is more commonly associated with people over the age of 65. The most common forms of dementia are Alzheimer’s disease, vascular dementia, dementia with Lewy bodies, fronto-temporal lobar degeneration, Huntington’s disease, alcohol related dementia, CreutzfeldtJakob disease and Parkinson’s related dementia. There are a number of conditions that produce symptoms similar to dementia. These include some vitamin and hormone deficiencies, depression, medication clashes or overmedication, infections and brain tumours. It is essential that a medical diagnosis is obtained at an early stage when symptoms first appear to ensure that a person who has a treatable condition is diagnosed and treated correctly. If the symptoms are caused by dementia, an early diagnosis will mean early access to support, information and medication. The early signs of dementia are very subtle and vague and may not be immediately obvious. Some common symptoms may include progressive and frequent memory loss, confusion, personality change, apathy and withdrawal and loss of ability to perform everyday tasks. At present there is no prevention or cure for most forms of dementia. However, some medications have been found to reduce symptoms. Recently, the American Psychiatric Association through the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5)3 has sought to introduce the terms ‘major’ and ‘minor’ neurocognitive disorders to simplify the varied presentations of dementia and remove the stigma associated with it and associated conditions. Dementia is a global health problem affecting an estimated 35.6 million people. This number will double by 2030 and more than triple by 2050.4 The first forum of the leading industrialized countries (G8) held a dementia summit in London in December 2013. The forum brought together ministers, researchers, pharmaceutical companies and charities to discuss investment and innovation in dementia research, and how to improve the prevention and treatment of dementia and quality of life for people with dementia. © 2015 Australian Dental Association
At this G8 meeting Jeremy Hunt, Secretary of State for Health in the UK outlined the human and economic costs of dementia: As life expectancy goes up, our generation has a unique challenge . . . One in three of us will get dementia. And if we don’t do better, for one in three those later years could be years of agony, heartbreak and despair . . . Thanks to [commitments made at the 2005 G8 summit in Gleneagles and the research that has followed] we have turned the global tide in the battle against AIDS. Now we need to do it again. We will bankrupt our healthcare systems if we don’t. Here in the UK the cost of dementia is £23 billion and globally it’s approaching $600 billion . . . But the real reason to do something about dementia is not financial. The real reason is human. Everyone deserves to live their final years with dignity, respect and the support of loved ones . . . At an earlier International Alzheimer’s Conference, UK Prime Minister David Cameron said: One of the greatest challenges of our time is what I’d call the quiet crisis, one that steals lives and tears at the hearts of families, but that relative to its impact is hardly acknowledged. We’ve got to treat this like the national crisis it is. We need an all-out fight-back against this disease; one that cuts across society. In a landmark paper in the New England Journal of Medicine5 the financial burden of dementia in the United States for 2010 was calculated to be US$157–215 billion. This figure extrapolated forward and globally will see expenditure on dementia exceeding that of cardiovascular disease and cancer within a relatively short time frame. It will be a huge burden on the global economy, in particular Australia. As Australians already have one of the highest life expectancies in the world and dementia is age related, our problems will be more severe, both socially and economically, compared to countries with lower life expectancies. How we live out our senior years varies throughout the world. In Europe, except for the UK and throughout Scandinavia and most of Asia, it is quite common to remain in the family home until the end and move into a residential aged care facility (RACF) only when cognitive decline precludes adequate home care. In the UK, USA and Australia the elderly often sell the family home and move into a retirement village or a nursing home. The level of care available in a RACF varies considerably. Some privately run facilities are more like hotels with private rooms and extensive facilities, 87
P Foltyn whereas others have four to six residents in a room with an all pervading smell of urine. As the level of remuneration for nursing home staff in Australia is generally the lowest amongst health care workers, many of the positions are filled by staff for whom English is their second language. Their level of care and commitment to the elderly is not in question; however, once their English language skills improve many transition to better paying positions or occupations with better long-term prospects. This compares poorly to some countries where, for example, the average length of employment at a rural Swedish nursing home was 14 years. The respect and reverence shown to the elderly by many cultures is not reflected in the way we regard our seniors as we have one of the highest levels of RACF admissions in the world. WHY ORAL HEALTH IS IMPORTANT Maintaining teeth and good periodontal health throughout life benefits diet, nutrition, general health and well-being. In many societies the appearance of an individual’s teeth reflects their social standing. When we smile we show our teeth. Damaged, discoloured or missing teeth may cause embarrassment and affect communication with others.6,7 Almost twothirds of respondents in a Dutch study reported that the appearance of their teeth contributed positively to their happiness.8 Health care in old age becomes difficult when frailty and dependency disturbs life’s routines, such as oral hygiene and attending a dentist. Residents with dementia in nursing homes may find that oral health deteriorates quite rapidly, primarily due to a lack of access to dental care.9 The World Health Organization (WHO) has expressed concern that the oral health of older people is widely neglected. Based on a global survey of older people WHO has called for public health action by strengthening health promotion, integrating disease prevention and improving age-friendly primary oral health care. Exclusion of cognitively impaired older adults in the past has led to widespread under reporting of poor oral health status.10 Japanese research11 has concluded that better oral and dental health in the elderly leads to better nutrition, increased confidence, better socialization and better communication. ALZHEIMER’S DISEASE AND ORAL HEALTH A study by Sparks12–15 and several other authors provided initial data that demonstrated elevated antibodies to periodontopathic microorganisms in subjects years before cognitive impairment and suggests that periodontal disease could potentially contribute to the 88
risk of Alzheimer’s disease onset and progression. Additional cohort studies profiling oral clinical presentation with systemic response and Alzheimer’s disease and prospective studies to evaluate any cause-andeffect association are warranted. As the costs associated with maintaining a clean and healthy mouth are minimal compared to the costs associated in managing Alzheimer’s, oral and dental care must be part of every older person’s care plan. A clean and healthy mouth is a priority for the elderly. Today’s elderly have generally placed a much higher value on good health than in previous generations, including oral and dental health. Frail older people are positively influenced by natural teeth and this effect seems to increase with increasing frailty.16 Preservation of teeth contributes to a positive body image and self-worth. Oral care for the elderly should aim to preserve as many functional teeth as possible. Many elderly have had good regular dental care and in many instances complex dental procedures. However, when we combine the effects of salivary gland hypofunction, xerostomia, polypharmacy, systemic health, cognitive impairment, poor fine motor skills, a poor swallowing reflex and a lack of motivation, the mouth can be the source of microorganisms associated with aspiration pneumonia, one of the leading causes of death in the elderly.17 There is a higher risk in those who are chronically or terminally ill. As the same microrganisms found in the mouth, around the teeth and poorly maintained dentures are linked to this particular pneumonia, both natural and artificial teeth and periodontal health need constant care. GERIATRIC GIANTS Sir Bernard Isaacs coined the term ‘Geriatric Giant’ in the 1960s to describe categories of impairments in the elderly.18 Falls were associated with frailty which in turn were associated with neurocognitive decline and delirium as an older person became less agile and in deteriorating health. Over time and as life expectancies increased, other important milestones that affected the elderly were added by various interest groups such as incontinence, vision impairment, hearing loss, sleep impairment, skin breakdown, polypharmacy and pharmacokinetics. As dental and oral health issues are a newly recognized burden on the health of the elderly, only scant regard for the implications of overt dental caries and active periodontal infection has occurred. However, as health issues for the elderly are interconnected, maintaining poor oral health can have consequences that are not immediately evident. A clean healthy mouth is essential. However, oral health management of the elderly cannot proceed in isolation, requiring a multidisciplinary approach. An individual’s own assessment of their oral health needs © 2015 Australian Dental Association
Ageing, dementia and oral health must be taken into account, together with that of their family, carer or nursing staff. As much as endodontic treatment may benefit an individual tooth, complete management often involves additional treatment and with it potential logistical difficulties precluding optimal care. Understanding that life expectancy is impacted by systemic health and the ‘Geriatric Giants’, the dental professional’s role is to make the individual comfortable and maintain function as best possible. ORAL CANCER Historically, more than 90% of oral cancers were reported in people over the age of 40 with the average age being about 63 and closely associated with alcohol and tobacco use.19 Significantly, the population growth rate in over 60s is greater than for any other age group and will lead to a greatly increased prevalence of oral cancer in the elderly. Since 2010, over 3100 new cases of head and neck cancer are diagnosed annually in Australia,20 with many of these occurring in the mouth. More recently, human papilloma virus (HPV) has been conclusively linked to oropharyngeal cancers in younger persons and will lead to a reduction in the average age at initial presentation. Oral cancers are one of the easiest to detect and commonly occur on the lip, tongue, floor of mouth, buccal mucosa, gingiva and palate but can appear on any area within the mouth. Pain is rarely an early symptom of oral cancer. The cancer may appear as a white or red patch, a change in texture of oral tissues, lymphadenopathy, ulceration or a lump in the neck. Any sudden unexplained speech patterns, difficulty in swallowing, excessive bleeding from gingival margins or any oral site must be explored as they may be early signs and symptoms of oral cancer. As dentists and dental hygienists routinely examine the oral cavity they must include an oral cancer examination as a matter of routine for the elderly. As most ulcerations, swellings and colour changes in the mouth are not cancer, but may be caused by local factors or are manifestations of other illnesses, a biopsy or other investigation should be considered if they have been present for 14 days or more. Early identification followed by appropriate management can elevate the rate of complete cure to nearly 80 to 90%, significantly improving quality of life, whereas late diagnosis is associated with extensive, invasive and often debilitating combinations of surgery, radiotherapy and chemotherapy and increased morbidity and reduced longevity. CASE REPORTS The following case reports illustrate the complexities in managing the elderly. © 2015 Australian Dental Association
Fig. 1 CT OPG for case report 2.
Case report 1 In 2011, a dental colleague related the story of his father who was a well-respected prosthodontist. When his father was diagnosed with dementia and could no longer be cared for in the family home he was admitted into a rural RACF. He was devastated that his father needed a full dental clearance after being in the RACF for 12 months. His father had gone from 1 to 3 cups of tea per day without sugar when he worked or lived at home to 10 cups of tea and coffee with at least eight spoons of sugar, plus countless cordials, juices, soft drinks, chocolates, cakes and biscuits. As aggressive and violent behaviour is not uncommon in those with moderate to severe dementia, RACFs routinely use sugar and sweetened products in a variety of ways. A spoonful of sugar, honey or jam has been found to calm difficult to manage residents and crushing medications and mixing with jam is a common standing order on medication charts. This high frequency consumption of sugars, in combination with often impaired salivary flow and lack of adequate oral care can have catastrophic consequences. Case report 2 This case is of a 79-year-old male who was a high functioning professional prior to his diagnosis three months earlier with Lewy body dementia. He woke one morning with a significant swelling on the left side of his face, had a high fever, was incoherent, agitated, confused and uncooperative. A conventional orthopantomograph (OPG) was not possible as he was unable to stand or even sit still in a wheelchair. A facial bone computed tomography (CT) was ordered and a simulated OPG created from the CT data (Fig. 1). The radiograph showed he had a near full complement of teeth and although heavily restored he had generally maintained good oral health. This 89
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Fig. 2 CT OPG for case report 3.
reconstructed OPG revealed a dental abscess associated with the lower left third molar. After 48 hours of intravenous (IV) antibiotics the swelling had reduced; however, there was still significant trismus present. Dental examination was problematic as he kept moving his head and biting. The only option was to remove this single tooth under a general anaesthetic. The anaesthetist reluctantly agreed to allow the extraction to proceed and this was scheduled for day 5 of his admission. The implications of exacerbating his cognitive impairment with a general anaesthetic were discussed with his wife and family. On the morning of day 5 the ward rang to advise that he had taken a bad turn resulting in the cancellation of the general anaesthetic. Eventually, the extraction proceeded on day 9. His trismus had improved, providing sufficient access to remove the tooth. Even though it was day 9 there was still frank pus present after the tooth was extracted. He was eventually discharged on day 29, not to the family home but to an aged care facility and a questionable future. Case report 3 The next case is of an 84-year-old male who had over the previous 18 months spiked fevers of unknown origin. He had dementia and was living at home being cared for by his devoted wife. She observed periodic changes in his behaviour which included mood changes, increased temperatures, incoherent speech, delirium and lack of appetite. On previous occasions it was assumed he had a urinary tract infection and was prescribed antibiotics which cleared his symptoms. On this occasion he developed a facial swelling centred on the right mandible. His wife felt that some of his teeth were loose and commented that he was also slapping the right side of his face with his hand. A conventional OPG was not possible and a CT OPG ordered (Fig. 2). Both distal lower molar teeth supporting 4 unit bridges had periapical lesions and 90
Fig. 3 OPG for case report 4 at baseline.
Fig. 4 OPG for case report 4 after 8 months.
exhibited carious root fractures. Both bridges were removed under a general anaesthetic and the patient discharged after 48 hours. Both cases 2 and 3 present many confronting issues for dentists. Can any public hospital system or private insurance afford this level of care for teeth? What’s going to happen when further teeth deteriorate or in the future when there will be an increasing number of baby boomers turning 85, who are cognitively impaired and have complex restored dentitions with neither the inclination or the manual skills to provide the level of oral care to avoid rapid root caries and aggressive periodontal disease? Implants are being placed for 90-year-olds and will continue into the
Fig. 5 OPG for case report 5 at baseline. © 2015 Australian Dental Association
Ageing, dementia and oral health Case report 5 A 66-year-old male had a routine OPG taken when presenting with pain in the left mandible (Fig. 5). The left mandibular first molar was extracted uneventfully; however, he was lost to follow-up for two years. On his return little was left of his teeth (Fig. 6). He had gone from living in his own home to a RACF where he was on multiple medications and no oral care was provided. Case report 6 Fig. 6 OPG for case report 5 after 2 years.
future; however, there needs to be a balance between their functional benefit and the person’s ability to maintain them. Complex and heroic prosthetic solutions need to be avoided in the patient who can’t demonstrate good manual dexterity skills and who doesn’t have the cognitive ability to understand how to care for their mouth properly. Having a full-time carer doesn’t guarantee that flossing and interdental brushing will take place. Locator abutments and mini dental implants to support dentures can generally be managed and restoring the dentition in this manner will assist in nutrition. Case report 4 A 45-year-old male had a routine OPG taken which did not demonstrate any overt interproximal caries. Although bitewing X-rays are preferable, an OPG is ideal for a minimally resourced public dental facility (Fig. 3). Within a week of the OPG his medications were changed and overnight he became xerostomic. He became housebound and didn’t receive any oral care or advice for the next eight months. He became depressed and compensated by eating junk food. An OPG taken eight months later highlights how rapid caries can progress in such a setting (Fig. 4).
An 86-year-old male admitted spiking fevers and a pronounced left sided lymphadenopathy. He had Alzheimer’s disease and lived at home with his wife as well as receiving 24-hour care. Due to his condition a conventional OPG was not possible and a CT OPG arranged under heavy sedation. The CT OPG did not provide any definitive information but showed the lower dentition restored with an implant retained prosthesis (Fig. 7). His wife, who was of a similar age but cognitively more alert, was unable to recall the name of the dentist who placed the implants. The next day a family member rang and suggested the names of two dentists that their father may have attended. Fortunately, the patient’s name was immediately known to the receptionist of one of the practices and the details of his implant placement confirmed. Ten years earlier he had an implant retained fixed denture made by a highly skilled and experienced dentist. For the next four years he attended the dental practice for regular dental and hygienist reviews. He was lost to followup, with the dentist only becoming aware of his acute presentation when the practice was contacted for information. As good records were kept by both the dentist and the maxillofacial surgeon who placed the fixtures, the implant specifications were provided as disassembly was a consideration. A more thorough examination was arranged under sedation and a compacted bolus of debris was retrieved from under the left side of the fixed denture. Within 24 hours his lymphadenopathy was reduced, enabling him to be discharged. Very few carers have any knowledge of oral health and are engaged primarily to assist the elderly by preparing meals, toileting, cleaning, dispensing medication and companionship. For the six years after he stopped seeing his dentist the implant retained fixed denture received no attention. Case report 7
Fig. 7 CT OPG for case report 6. © 2015 Australian Dental Association
An 86-year-old immobile female with dementia residing in a RACF had a fixed maxillary reconstruction 91
P Foltyn Case report 8
Fig. 8 Periapical radiograph for case report 8.
A 104-year-old female nursing home resident who was cognitively and systemically well, took minimal medications and drank one-third of a bottle of brandy per day. She developed a symptomatic draining fistula associated with one of her lower incisors (Fig. 8 and 9). She refused to take oral antibiotics as in the past she had always suffered stomach upset, diarrhoea, cramps and dehydration. However, she did agree to daily intramuscular antibiotics administered by the visiting medical practitioner. There was an expectation that the extraction would be quite straightforward; however, gaining the confidence of the patient and family that there would be an appropriate level of observation and opportunity for intervention should there be a post-extraction complication could not be guaranteed if the extraction was done in the nursing home. With the full cooperation of the St Vincent’s Hospital Emergency Department, the patient was brought into their department and administered two doses of intravenous antibiotics before the two incisor teeth were removed, the abscess curetted and the area irrigated later that afternoon. She was provided with a casual bed overnight and discharged the following morning after dental review. Referral to the hospital’s geriatric unit was also considered; however, the logistics of arranging the admission directly from the nursing home were outweighed by the higher staffing level and ease of arranging supervision in the emergency department. Post-extraction healing was uneventful and the staff were quite happy for her to continue her regular nightcap of brandy IS THERE A WAY FORWARD?
Fig. 9 Clinical photograph for case report 8.
several years earlier. Neither her or her daughter could recall the name or location of the dentist. Periimplantitis was present around one of the fixtures and a prosthodontist was asked to review her at the nursing home. In the area of peri-implantitis, a fixture was found to have a broken screw; however, the brand of implant was not readily identifiable from a periapical radiograph. Due to her immobility referral for additional imaging was not deemed feasible. Fortunately, the facility had a dental clinic with a resident dental hygienist who was able to see her weekly and help her maintain oral health in that area. 92
In the Journal of the Canadian Dental Association in 2011 Brian Barrett published an article titled ‘The looming geriatric dental care crisis’.21 This was the same title he used in another article published in 1998.22 He had only been in dental practice for 10 years in 1998 and had developed a concern for the elderly in long-term care facilities. Even at that time, ‘looming’ was an understatement. Barrett lamented that the last 20 years had shown the problem of geriatric dental care is here with a vengeance. He had seen very little in a practical manner to address the situation since his initial article was published. Over the course of his career he had attended at least four national conferences on the topic, with all attendees agreeing on possible solutions. Yet nothing was forthcoming to address the nightmare that was to come. In 1997, the Australian Commonwealth Government conducted the Senate Community Affairs References Committee Inquiry into Public Dental Services. © 2015 Australian Dental Association
Ageing, dementia and oral health Like Barrett, the author also predicted a pending disaster if there was inactivity on aged care: Oral health care has not been seen as a priority nor has it been fully appreciated by the medical profession and government. Many doctors have a limited working knowledge of oral and dental anatomy and the close relationship between oral health and general health. As we near the year 2000 many of our ‘baby boomers’ will be approaching retirement age. Some will be entering nursing homes or residential care facilities with most teeth intact, or heavily restored with extensive crowns and bridges, unlike the average 50–60 year old of a decade or two ago who was edentulous. Oral neglect by a nursing home or other facility will see teeth deteriorate significantly within twelve months of entry to that facility . . . Education and prevention strategies in oral health care must be put in place now in order to limit a disaster amongst our aged and disabled.23 Many dental professionals continue to struggle to provide dental treatment, institute preventive oral care recommendations, and reduce the progression of caries and other oral diseases and conditions for their institutionalized patients, especially those with dementia. Japan has taken a proactive approach in improving oral care in the elderly by ensuring anyone studying a dental discipline spends time in an aged care facility providing cleaning and oral care advice for residents, staff, family and carers. As the aged care sector in Australia is not well remunerated, many aged care facilities experience high levels of staff turnover which negates any effort to better educate staff on oral health. Staff generally struggle with basic needs such as toileting and personal hygiene, adequate hydration, getting to meals on time, getting to social activities, resident safety and meeting high standards of documentation and compliance with regulations. Assisted toothbrushing and other oral care is rarely a priority and often seen a ‘dirty’ part of the work. WE CAN DO BETTER – WE MUST DO BETTER Every dental practice has a role to play in improving the oral health of the elderly – the most vulnerable members of our communities. There are always opportunities for front office staff, the dentist, hygienist and oral health therapist to enquire about older members of a patient’s family even if they don’t attend the practice. Discussing the transformation of dental treatment for the elderly moving away from dentures to restorative and cosmetic procedures, and the importance of maintaining a functional and healthy dentition as we age may well bring the practice new patients. © 2015 Australian Dental Association
At present Australian doctors receive a special oneoff payment from Medicare for examination of 75year-olds; however, there is no political will at present to incorporate dental examinations of the elderly into Medicare. Doctors aren’t in a position to provide the comprehensive oral examination that is required at this age but we are. As doctors haven’t been educated on the implications of poor oral health in the elderly, it is important for dentists to liaise with their network of medical practitioners and create age relevant oral health information that they can pass on to their patients. A dental led Armageddon in the elderly is just around the corner and we are not prepared. DISCLOSURE The author has no conflicts of interest to declare.
REFERENCES 1. Australian Bureau of Statistics. Life Tables, States, Territories and Australia, 2011–2013. Available at: ‘http://www.abs.gov.au/ ausstats/[email protected]/mf/3302.0.55.001’. Accessed January 2015. 2. Alzheimer’s Australia. About dementia and memory loss. Help sheets. Available at: ‘http://fightdementia.org.au/about-dementiaand-memory-loss/help-sheets’. Accessed January 2015. 3. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: DSM-5. Washington, DC: American Psychiatric Association, 2013. 4. Chan M. Dementia: A Public Health Priority. World Health Organization and Alzheimer’s Disease International. Available at: http:// whqlibdoc.who.int/publications/2012/9789241564458_eng.pdf. Accessed August 2014. 5. Hurd MD, Martorell P, Delavande A, Mullen KJ, Langa KM. Monetary costs of dementia in the United States. N Engl J Med 2013;368:1326–1334. 6. Davis DM, Fiske J, Scott B, Radford DR. The emotional effects of tooth loss: a preliminary quantitative study. Br Dent J 2000;188:503–506. 7. Al-Omiri MK, Karasneh JA, Lynch E, Lamey PJ, Clifford TJ. Impacts of missing upper anterior teeth on daily living. Int Dent J 2009;59:127–132. 8. Gresnigt-Bekker CO, de Jongh A, Vo G, Lie F, OosterinkWubbe FM, van Rood Y. [Satisfaction about physical appearance and teeth. Results of a nationwide study]. Ned Tijdschr Tandheelkd 2008;115:369–373. 9. MacEntee MI. Oral Healthcare and The Frail Elder: A Clinical Perspective. Wiley-Blackwell, 2011. 10. Petersen PE, Yamamoto T. Improving the oral health of older people: the approach of the WHO Global Oral Health Programme. Community Dent Oral Epidemiol 2005; 33:81–92. 11. Shimazaki Y, Soh I, Saito T, et al. Influence of dentition status on physical disability, mental impairment, and mortality in institutionalized elderly people. J Dent Res 2001;80:340–345. 12. Sparks Stein P, Steffen MJ, Smith C, et al. Serum antibodies to periodontal pathogens are a risk factor for Alzheimer’s disease. Alzheimers Dement 2012;8:196–203. 13. Miklossy J. Alzheimer’s disease – a neurospirochetosis. Analysis of the evidence following Koch’s and Hill’s criteria. J Neuroinflammation 2011;8:90. 93
P Foltyn 14. Kamer AR, Craig RG, Dasanayake AP, Brys M, GlodzikSobanska L, de Leon MJ. Inflammation and Alzheimer’s disease: possible role of periodontal diseases. Alzheimers Dement 2008;4:242–250.
21. Barrett B. The looming geriatric dental care crisis. J Can Dent Assoc 2011;77:b2.
15. Watts A, Crimmins EM, Gatz M. Inflammation as a potential mediator for the association between periodontal disease and Alzheimer’s disease. Neuropsychiatr Dis Treat 2008;4:865–876.
23. Australian Government. Senate Community Affairs References Committee Report on Public Dental Services. Foltyn P. Page 14, 2.45. Available at: ‘http://www.aph.gov.au/~/media/wopapub/ senate/committee/clac_ctte/completed_inquiries/1996_99/dental/ report/report_pdf.ashx’. Accessed August 2014.
16. Niesten D, van Mourik K, van der Sanden W. The impact of having natural teeth on the QoL of frail dentulous older people. A qualitative study. BMC Public Health 2012;12:839. 17. Sarin J, Balasubramaniam R, Corcoran AM, Laudenbach JM, Stoopler ET. Reducing the risk of aspiration pneumonia among elderly patients in long-term care facilities through oral health interventions. J Am Med Dir Assoc 2008;9:128–135. 18. Isaacs B. The challenge of geriatric medicine. Oxford: Oxford University Press, 1992. 19. Foltyn P. Oral Cancer: Information for Dentists. The Kinghorn Cancer Centre and St Vincent’s Hospital. Available at: http:// tkcc.org.au/wp-content/uploads/2015/02/Oral-Cancer-Informationfor-Dentists.pdf. Accessed January 2015. 20. Cancer Council Australia. Available at: http://www.cancer.org. au/about-cancer/types-of-cancer/head-and-neck-cancer.html. Accessed January 2015.
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22. Barrett B. The looming geriatric dental care crisis. J Can Dent Assoc 1998;64:623–624.
Address for correspondence: Dr Peter Foltyn Conjoint Senior Lecturer UNSW Dental Department St Vincent’s Hospital Victoria Street Darlinghurst NSW 2010 Email: [email protected]
© 2015 Australian Dental Association
The official journal of the Australian Dental Association
Australian Dental Journal 2015; 60:(1 Suppl): 86–94 doi: 10.1111/adj.12287
Ageing, dementia and oral health P Foltyn* *Dental Department, St Vincent’s Hospital, Darlinghurst, New South Wales, Australia.
ABSTRACT Neurocognitive decline and delirium, frailty, incontinence, falls, hearing and vision impairment, medication compliance and pharmacokinetics, skin breakdown, impaired sleep and rest are regarded as geriatric giants by gerontologists, geriatricians and nursing home staff. As these are all interrelated in the elderly, failure to act on one can impact on the others. However, the implications of poor oral health have for too long been ignored and deserve equal status. Mouth pain can be devastating for the elderly, compound psychosocial problems, frustrate carers and nursing home staff and disrupt family dynamics. As appearance, function and comfort suffer, so may a person’s self-esteem and confidence. The contributing factors for poor oral health such as rapid dental decay, acute and chronic periodontal infections and compromised systemic health on a background of a dry mouth, coupled with xerostomia-inducing medications, reduced fine motor function, declining cognition and motivation will not only lead to an increase in both morbidity and mortality but also impact on quality of life. Keywords: Elderly, frail, geriatric, gerontology, oral health. Abbreviations and acronyms: ABS = Australian Bureau of Statistics; CT = computed tomography; OPG = orthopantomograph; RACF = residential aged care facility.
AGEING Ageing is a natural biological process which is primarily influenced by our genetic makeup. However, in recent centuries it has become more heavily influenced by social, environmental, economic and medical changes as well as physical and mental health. In 19th century Britain being over 50 was regarded as old whereas in Australia a new pensionable age of 70 was proposed in the 2014 Federal budget. In the 1950s Australia had a high level of prosperity and enjoyed the benefits of being dubbed the ‘lucky country’. However, like many aspects of health care dentistry had not progressed far beyond amalgam fillings and extractions over the previous decades. If you were in your late 60s in the early 1950s you would have been considered old. Many ‘old’ people then had no natural teeth and dental care was about extractions and getting a good set of dentures. In those days some rural women were sent to the dentist to have all their teeth removed so that they wouldn’t be a burden on their future husbands. As a result of better oral health education and many parts of Australia adopting water fluoridation in the 1960s, we now find many 50-year-olds who had access to fluoridated water in their formative years 86
have had a negligible number of carious lesions and many 80- and 90-year-olds have a functional dentition. Sadly over recent years, an increased consumption of sugared drinks and snack foods has seen increased caries rates in today’s youth. The Australian Bureau of Statistics (ABS) produces Life Tables1 every two years which reveal that the average 85-year-old male now lives for a further 6.1 years whilst the average 85-year-old female a further 7.1 years. These figures have fluctuated over successive reporting periods but are generally on a gradual increase, which means that the average 85year-old in 20 years’ time could expect to live well into their 90s. Although increasing rates of diabetes and obesity may slow these figures down, they are countered by decreasing levels of smoking. 2010 was a landmark year as the first of the postWorld War II baby boomers turned 65. Baby boomers are the bulge in Australia’s and most of the western world’s demographic profile. The next decade will see a greater acceleration of the many medical, social, communal and economic impacts of ageing and dementia than previously seen in Australia’s history. If our youth survive childhood illnesses, cures or better treatment regimes are developed for some of the common cancers, smoking rates are reduced further, © 2015 Australian Dental Association
Ageing, dementia and oral health they don’t binge drink and overeat, exercise even moderately and don’t drive motor vehicles at excessive speeds, most children born today will reach 100 years of age. DEMENTIA Dementia2 describes a collection of symptoms caused by disorders affecting the brain. It is not one specific disease. Dementia affects thinking, behaviour and the ability to perform everyday tasks. Brain function is affected enough to interfere with the person’s normal social or working life. Dementia can occur at any age; however, it is more commonly associated with people over the age of 65. The most common forms of dementia are Alzheimer’s disease, vascular dementia, dementia with Lewy bodies, fronto-temporal lobar degeneration, Huntington’s disease, alcohol related dementia, CreutzfeldtJakob disease and Parkinson’s related dementia. There are a number of conditions that produce symptoms similar to dementia. These include some vitamin and hormone deficiencies, depression, medication clashes or overmedication, infections and brain tumours. It is essential that a medical diagnosis is obtained at an early stage when symptoms first appear to ensure that a person who has a treatable condition is diagnosed and treated correctly. If the symptoms are caused by dementia, an early diagnosis will mean early access to support, information and medication. The early signs of dementia are very subtle and vague and may not be immediately obvious. Some common symptoms may include progressive and frequent memory loss, confusion, personality change, apathy and withdrawal and loss of ability to perform everyday tasks. At present there is no prevention or cure for most forms of dementia. However, some medications have been found to reduce symptoms. Recently, the American Psychiatric Association through the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5)3 has sought to introduce the terms ‘major’ and ‘minor’ neurocognitive disorders to simplify the varied presentations of dementia and remove the stigma associated with it and associated conditions. Dementia is a global health problem affecting an estimated 35.6 million people. This number will double by 2030 and more than triple by 2050.4 The first forum of the leading industrialized countries (G8) held a dementia summit in London in December 2013. The forum brought together ministers, researchers, pharmaceutical companies and charities to discuss investment and innovation in dementia research, and how to improve the prevention and treatment of dementia and quality of life for people with dementia. © 2015 Australian Dental Association
At this G8 meeting Jeremy Hunt, Secretary of State for Health in the UK outlined the human and economic costs of dementia: As life expectancy goes up, our generation has a unique challenge . . . One in three of us will get dementia. And if we don’t do better, for one in three those later years could be years of agony, heartbreak and despair . . . Thanks to [commitments made at the 2005 G8 summit in Gleneagles and the research that has followed] we have turned the global tide in the battle against AIDS. Now we need to do it again. We will bankrupt our healthcare systems if we don’t. Here in the UK the cost of dementia is £23 billion and globally it’s approaching $600 billion . . . But the real reason to do something about dementia is not financial. The real reason is human. Everyone deserves to live their final years with dignity, respect and the support of loved ones . . . At an earlier International Alzheimer’s Conference, UK Prime Minister David Cameron said: One of the greatest challenges of our time is what I’d call the quiet crisis, one that steals lives and tears at the hearts of families, but that relative to its impact is hardly acknowledged. We’ve got to treat this like the national crisis it is. We need an all-out fight-back against this disease; one that cuts across society. In a landmark paper in the New England Journal of Medicine5 the financial burden of dementia in the United States for 2010 was calculated to be US$157–215 billion. This figure extrapolated forward and globally will see expenditure on dementia exceeding that of cardiovascular disease and cancer within a relatively short time frame. It will be a huge burden on the global economy, in particular Australia. As Australians already have one of the highest life expectancies in the world and dementia is age related, our problems will be more severe, both socially and economically, compared to countries with lower life expectancies. How we live out our senior years varies throughout the world. In Europe, except for the UK and throughout Scandinavia and most of Asia, it is quite common to remain in the family home until the end and move into a residential aged care facility (RACF) only when cognitive decline precludes adequate home care. In the UK, USA and Australia the elderly often sell the family home and move into a retirement village or a nursing home. The level of care available in a RACF varies considerably. Some privately run facilities are more like hotels with private rooms and extensive facilities, 87
P Foltyn whereas others have four to six residents in a room with an all pervading smell of urine. As the level of remuneration for nursing home staff in Australia is generally the lowest amongst health care workers, many of the positions are filled by staff for whom English is their second language. Their level of care and commitment to the elderly is not in question; however, once their English language skills improve many transition to better paying positions or occupations with better long-term prospects. This compares poorly to some countries where, for example, the average length of employment at a rural Swedish nursing home was 14 years. The respect and reverence shown to the elderly by many cultures is not reflected in the way we regard our seniors as we have one of the highest levels of RACF admissions in the world. WHY ORAL HEALTH IS IMPORTANT Maintaining teeth and good periodontal health throughout life benefits diet, nutrition, general health and well-being. In many societies the appearance of an individual’s teeth reflects their social standing. When we smile we show our teeth. Damaged, discoloured or missing teeth may cause embarrassment and affect communication with others.6,7 Almost twothirds of respondents in a Dutch study reported that the appearance of their teeth contributed positively to their happiness.8 Health care in old age becomes difficult when frailty and dependency disturbs life’s routines, such as oral hygiene and attending a dentist. Residents with dementia in nursing homes may find that oral health deteriorates quite rapidly, primarily due to a lack of access to dental care.9 The World Health Organization (WHO) has expressed concern that the oral health of older people is widely neglected. Based on a global survey of older people WHO has called for public health action by strengthening health promotion, integrating disease prevention and improving age-friendly primary oral health care. Exclusion of cognitively impaired older adults in the past has led to widespread under reporting of poor oral health status.10 Japanese research11 has concluded that better oral and dental health in the elderly leads to better nutrition, increased confidence, better socialization and better communication. ALZHEIMER’S DISEASE AND ORAL HEALTH A study by Sparks12–15 and several other authors provided initial data that demonstrated elevated antibodies to periodontopathic microorganisms in subjects years before cognitive impairment and suggests that periodontal disease could potentially contribute to the 88
risk of Alzheimer’s disease onset and progression. Additional cohort studies profiling oral clinical presentation with systemic response and Alzheimer’s disease and prospective studies to evaluate any cause-andeffect association are warranted. As the costs associated with maintaining a clean and healthy mouth are minimal compared to the costs associated in managing Alzheimer’s, oral and dental care must be part of every older person’s care plan. A clean and healthy mouth is a priority for the elderly. Today’s elderly have generally placed a much higher value on good health than in previous generations, including oral and dental health. Frail older people are positively influenced by natural teeth and this effect seems to increase with increasing frailty.16 Preservation of teeth contributes to a positive body image and self-worth. Oral care for the elderly should aim to preserve as many functional teeth as possible. Many elderly have had good regular dental care and in many instances complex dental procedures. However, when we combine the effects of salivary gland hypofunction, xerostomia, polypharmacy, systemic health, cognitive impairment, poor fine motor skills, a poor swallowing reflex and a lack of motivation, the mouth can be the source of microorganisms associated with aspiration pneumonia, one of the leading causes of death in the elderly.17 There is a higher risk in those who are chronically or terminally ill. As the same microrganisms found in the mouth, around the teeth and poorly maintained dentures are linked to this particular pneumonia, both natural and artificial teeth and periodontal health need constant care. GERIATRIC GIANTS Sir Bernard Isaacs coined the term ‘Geriatric Giant’ in the 1960s to describe categories of impairments in the elderly.18 Falls were associated with frailty which in turn were associated with neurocognitive decline and delirium as an older person became less agile and in deteriorating health. Over time and as life expectancies increased, other important milestones that affected the elderly were added by various interest groups such as incontinence, vision impairment, hearing loss, sleep impairment, skin breakdown, polypharmacy and pharmacokinetics. As dental and oral health issues are a newly recognized burden on the health of the elderly, only scant regard for the implications of overt dental caries and active periodontal infection has occurred. However, as health issues for the elderly are interconnected, maintaining poor oral health can have consequences that are not immediately evident. A clean healthy mouth is essential. However, oral health management of the elderly cannot proceed in isolation, requiring a multidisciplinary approach. An individual’s own assessment of their oral health needs © 2015 Australian Dental Association
Ageing, dementia and oral health must be taken into account, together with that of their family, carer or nursing staff. As much as endodontic treatment may benefit an individual tooth, complete management often involves additional treatment and with it potential logistical difficulties precluding optimal care. Understanding that life expectancy is impacted by systemic health and the ‘Geriatric Giants’, the dental professional’s role is to make the individual comfortable and maintain function as best possible. ORAL CANCER Historically, more than 90% of oral cancers were reported in people over the age of 40 with the average age being about 63 and closely associated with alcohol and tobacco use.19 Significantly, the population growth rate in over 60s is greater than for any other age group and will lead to a greatly increased prevalence of oral cancer in the elderly. Since 2010, over 3100 new cases of head and neck cancer are diagnosed annually in Australia,20 with many of these occurring in the mouth. More recently, human papilloma virus (HPV) has been conclusively linked to oropharyngeal cancers in younger persons and will lead to a reduction in the average age at initial presentation. Oral cancers are one of the easiest to detect and commonly occur on the lip, tongue, floor of mouth, buccal mucosa, gingiva and palate but can appear on any area within the mouth. Pain is rarely an early symptom of oral cancer. The cancer may appear as a white or red patch, a change in texture of oral tissues, lymphadenopathy, ulceration or a lump in the neck. Any sudden unexplained speech patterns, difficulty in swallowing, excessive bleeding from gingival margins or any oral site must be explored as they may be early signs and symptoms of oral cancer. As dentists and dental hygienists routinely examine the oral cavity they must include an oral cancer examination as a matter of routine for the elderly. As most ulcerations, swellings and colour changes in the mouth are not cancer, but may be caused by local factors or are manifestations of other illnesses, a biopsy or other investigation should be considered if they have been present for 14 days or more. Early identification followed by appropriate management can elevate the rate of complete cure to nearly 80 to 90%, significantly improving quality of life, whereas late diagnosis is associated with extensive, invasive and often debilitating combinations of surgery, radiotherapy and chemotherapy and increased morbidity and reduced longevity. CASE REPORTS The following case reports illustrate the complexities in managing the elderly. © 2015 Australian Dental Association
Fig. 1 CT OPG for case report 2.
Case report 1 In 2011, a dental colleague related the story of his father who was a well-respected prosthodontist. When his father was diagnosed with dementia and could no longer be cared for in the family home he was admitted into a rural RACF. He was devastated that his father needed a full dental clearance after being in the RACF for 12 months. His father had gone from 1 to 3 cups of tea per day without sugar when he worked or lived at home to 10 cups of tea and coffee with at least eight spoons of sugar, plus countless cordials, juices, soft drinks, chocolates, cakes and biscuits. As aggressive and violent behaviour is not uncommon in those with moderate to severe dementia, RACFs routinely use sugar and sweetened products in a variety of ways. A spoonful of sugar, honey or jam has been found to calm difficult to manage residents and crushing medications and mixing with jam is a common standing order on medication charts. This high frequency consumption of sugars, in combination with often impaired salivary flow and lack of adequate oral care can have catastrophic consequences. Case report 2 This case is of a 79-year-old male who was a high functioning professional prior to his diagnosis three months earlier with Lewy body dementia. He woke one morning with a significant swelling on the left side of his face, had a high fever, was incoherent, agitated, confused and uncooperative. A conventional orthopantomograph (OPG) was not possible as he was unable to stand or even sit still in a wheelchair. A facial bone computed tomography (CT) was ordered and a simulated OPG created from the CT data (Fig. 1). The radiograph showed he had a near full complement of teeth and although heavily restored he had generally maintained good oral health. This 89
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Fig. 2 CT OPG for case report 3.
reconstructed OPG revealed a dental abscess associated with the lower left third molar. After 48 hours of intravenous (IV) antibiotics the swelling had reduced; however, there was still significant trismus present. Dental examination was problematic as he kept moving his head and biting. The only option was to remove this single tooth under a general anaesthetic. The anaesthetist reluctantly agreed to allow the extraction to proceed and this was scheduled for day 5 of his admission. The implications of exacerbating his cognitive impairment with a general anaesthetic were discussed with his wife and family. On the morning of day 5 the ward rang to advise that he had taken a bad turn resulting in the cancellation of the general anaesthetic. Eventually, the extraction proceeded on day 9. His trismus had improved, providing sufficient access to remove the tooth. Even though it was day 9 there was still frank pus present after the tooth was extracted. He was eventually discharged on day 29, not to the family home but to an aged care facility and a questionable future. Case report 3 The next case is of an 84-year-old male who had over the previous 18 months spiked fevers of unknown origin. He had dementia and was living at home being cared for by his devoted wife. She observed periodic changes in his behaviour which included mood changes, increased temperatures, incoherent speech, delirium and lack of appetite. On previous occasions it was assumed he had a urinary tract infection and was prescribed antibiotics which cleared his symptoms. On this occasion he developed a facial swelling centred on the right mandible. His wife felt that some of his teeth were loose and commented that he was also slapping the right side of his face with his hand. A conventional OPG was not possible and a CT OPG ordered (Fig. 2). Both distal lower molar teeth supporting 4 unit bridges had periapical lesions and 90
Fig. 3 OPG for case report 4 at baseline.
Fig. 4 OPG for case report 4 after 8 months.
exhibited carious root fractures. Both bridges were removed under a general anaesthetic and the patient discharged after 48 hours. Both cases 2 and 3 present many confronting issues for dentists. Can any public hospital system or private insurance afford this level of care for teeth? What’s going to happen when further teeth deteriorate or in the future when there will be an increasing number of baby boomers turning 85, who are cognitively impaired and have complex restored dentitions with neither the inclination or the manual skills to provide the level of oral care to avoid rapid root caries and aggressive periodontal disease? Implants are being placed for 90-year-olds and will continue into the
Fig. 5 OPG for case report 5 at baseline. © 2015 Australian Dental Association
Ageing, dementia and oral health Case report 5 A 66-year-old male had a routine OPG taken when presenting with pain in the left mandible (Fig. 5). The left mandibular first molar was extracted uneventfully; however, he was lost to follow-up for two years. On his return little was left of his teeth (Fig. 6). He had gone from living in his own home to a RACF where he was on multiple medications and no oral care was provided. Case report 6 Fig. 6 OPG for case report 5 after 2 years.
future; however, there needs to be a balance between their functional benefit and the person’s ability to maintain them. Complex and heroic prosthetic solutions need to be avoided in the patient who can’t demonstrate good manual dexterity skills and who doesn’t have the cognitive ability to understand how to care for their mouth properly. Having a full-time carer doesn’t guarantee that flossing and interdental brushing will take place. Locator abutments and mini dental implants to support dentures can generally be managed and restoring the dentition in this manner will assist in nutrition. Case report 4 A 45-year-old male had a routine OPG taken which did not demonstrate any overt interproximal caries. Although bitewing X-rays are preferable, an OPG is ideal for a minimally resourced public dental facility (Fig. 3). Within a week of the OPG his medications were changed and overnight he became xerostomic. He became housebound and didn’t receive any oral care or advice for the next eight months. He became depressed and compensated by eating junk food. An OPG taken eight months later highlights how rapid caries can progress in such a setting (Fig. 4).
An 86-year-old male admitted spiking fevers and a pronounced left sided lymphadenopathy. He had Alzheimer’s disease and lived at home with his wife as well as receiving 24-hour care. Due to his condition a conventional OPG was not possible and a CT OPG arranged under heavy sedation. The CT OPG did not provide any definitive information but showed the lower dentition restored with an implant retained prosthesis (Fig. 7). His wife, who was of a similar age but cognitively more alert, was unable to recall the name of the dentist who placed the implants. The next day a family member rang and suggested the names of two dentists that their father may have attended. Fortunately, the patient’s name was immediately known to the receptionist of one of the practices and the details of his implant placement confirmed. Ten years earlier he had an implant retained fixed denture made by a highly skilled and experienced dentist. For the next four years he attended the dental practice for regular dental and hygienist reviews. He was lost to followup, with the dentist only becoming aware of his acute presentation when the practice was contacted for information. As good records were kept by both the dentist and the maxillofacial surgeon who placed the fixtures, the implant specifications were provided as disassembly was a consideration. A more thorough examination was arranged under sedation and a compacted bolus of debris was retrieved from under the left side of the fixed denture. Within 24 hours his lymphadenopathy was reduced, enabling him to be discharged. Very few carers have any knowledge of oral health and are engaged primarily to assist the elderly by preparing meals, toileting, cleaning, dispensing medication and companionship. For the six years after he stopped seeing his dentist the implant retained fixed denture received no attention. Case report 7
Fig. 7 CT OPG for case report 6. © 2015 Australian Dental Association
An 86-year-old immobile female with dementia residing in a RACF had a fixed maxillary reconstruction 91
P Foltyn Case report 8
Fig. 8 Periapical radiograph for case report 8.
A 104-year-old female nursing home resident who was cognitively and systemically well, took minimal medications and drank one-third of a bottle of brandy per day. She developed a symptomatic draining fistula associated with one of her lower incisors (Fig. 8 and 9). She refused to take oral antibiotics as in the past she had always suffered stomach upset, diarrhoea, cramps and dehydration. However, she did agree to daily intramuscular antibiotics administered by the visiting medical practitioner. There was an expectation that the extraction would be quite straightforward; however, gaining the confidence of the patient and family that there would be an appropriate level of observation and opportunity for intervention should there be a post-extraction complication could not be guaranteed if the extraction was done in the nursing home. With the full cooperation of the St Vincent’s Hospital Emergency Department, the patient was brought into their department and administered two doses of intravenous antibiotics before the two incisor teeth were removed, the abscess curetted and the area irrigated later that afternoon. She was provided with a casual bed overnight and discharged the following morning after dental review. Referral to the hospital’s geriatric unit was also considered; however, the logistics of arranging the admission directly from the nursing home were outweighed by the higher staffing level and ease of arranging supervision in the emergency department. Post-extraction healing was uneventful and the staff were quite happy for her to continue her regular nightcap of brandy IS THERE A WAY FORWARD?
Fig. 9 Clinical photograph for case report 8.
several years earlier. Neither her or her daughter could recall the name or location of the dentist. Periimplantitis was present around one of the fixtures and a prosthodontist was asked to review her at the nursing home. In the area of peri-implantitis, a fixture was found to have a broken screw; however, the brand of implant was not readily identifiable from a periapical radiograph. Due to her immobility referral for additional imaging was not deemed feasible. Fortunately, the facility had a dental clinic with a resident dental hygienist who was able to see her weekly and help her maintain oral health in that area. 92
In the Journal of the Canadian Dental Association in 2011 Brian Barrett published an article titled ‘The looming geriatric dental care crisis’.21 This was the same title he used in another article published in 1998.22 He had only been in dental practice for 10 years in 1998 and had developed a concern for the elderly in long-term care facilities. Even at that time, ‘looming’ was an understatement. Barrett lamented that the last 20 years had shown the problem of geriatric dental care is here with a vengeance. He had seen very little in a practical manner to address the situation since his initial article was published. Over the course of his career he had attended at least four national conferences on the topic, with all attendees agreeing on possible solutions. Yet nothing was forthcoming to address the nightmare that was to come. In 1997, the Australian Commonwealth Government conducted the Senate Community Affairs References Committee Inquiry into Public Dental Services. © 2015 Australian Dental Association
Ageing, dementia and oral health Like Barrett, the author also predicted a pending disaster if there was inactivity on aged care: Oral health care has not been seen as a priority nor has it been fully appreciated by the medical profession and government. Many doctors have a limited working knowledge of oral and dental anatomy and the close relationship between oral health and general health. As we near the year 2000 many of our ‘baby boomers’ will be approaching retirement age. Some will be entering nursing homes or residential care facilities with most teeth intact, or heavily restored with extensive crowns and bridges, unlike the average 50–60 year old of a decade or two ago who was edentulous. Oral neglect by a nursing home or other facility will see teeth deteriorate significantly within twelve months of entry to that facility . . . Education and prevention strategies in oral health care must be put in place now in order to limit a disaster amongst our aged and disabled.23 Many dental professionals continue to struggle to provide dental treatment, institute preventive oral care recommendations, and reduce the progression of caries and other oral diseases and conditions for their institutionalized patients, especially those with dementia. Japan has taken a proactive approach in improving oral care in the elderly by ensuring anyone studying a dental discipline spends time in an aged care facility providing cleaning and oral care advice for residents, staff, family and carers. As the aged care sector in Australia is not well remunerated, many aged care facilities experience high levels of staff turnover which negates any effort to better educate staff on oral health. Staff generally struggle with basic needs such as toileting and personal hygiene, adequate hydration, getting to meals on time, getting to social activities, resident safety and meeting high standards of documentation and compliance with regulations. Assisted toothbrushing and other oral care is rarely a priority and often seen a ‘dirty’ part of the work. WE CAN DO BETTER – WE MUST DO BETTER Every dental practice has a role to play in improving the oral health of the elderly – the most vulnerable members of our communities. There are always opportunities for front office staff, the dentist, hygienist and oral health therapist to enquire about older members of a patient’s family even if they don’t attend the practice. Discussing the transformation of dental treatment for the elderly moving away from dentures to restorative and cosmetic procedures, and the importance of maintaining a functional and healthy dentition as we age may well bring the practice new patients. © 2015 Australian Dental Association
At present Australian doctors receive a special oneoff payment from Medicare for examination of 75year-olds; however, there is no political will at present to incorporate dental examinations of the elderly into Medicare. Doctors aren’t in a position to provide the comprehensive oral examination that is required at this age but we are. As doctors haven’t been educated on the implications of poor oral health in the elderly, it is important for dentists to liaise with their network of medical practitioners and create age relevant oral health information that they can pass on to their patients. A dental led Armageddon in the elderly is just around the corner and we are not prepared. DISCLOSURE The author has no conflicts of interest to declare.
REFERENCES 1. Australian Bureau of Statistics. Life Tables, States, Territories and Australia, 2011–2013. Available at: ‘http://www.abs.gov.au/ ausstats/[email protected]/mf/3302.0.55.001’. Accessed January 2015. 2. Alzheimer’s Australia. About dementia and memory loss. Help sheets. Available at: ‘http://fightdementia.org.au/about-dementiaand-memory-loss/help-sheets’. Accessed January 2015. 3. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: DSM-5. Washington, DC: American Psychiatric Association, 2013. 4. Chan M. Dementia: A Public Health Priority. World Health Organization and Alzheimer’s Disease International. Available at: http:// whqlibdoc.who.int/publications/2012/9789241564458_eng.pdf. Accessed August 2014. 5. Hurd MD, Martorell P, Delavande A, Mullen KJ, Langa KM. Monetary costs of dementia in the United States. N Engl J Med 2013;368:1326–1334. 6. Davis DM, Fiske J, Scott B, Radford DR. The emotional effects of tooth loss: a preliminary quantitative study. Br Dent J 2000;188:503–506. 7. Al-Omiri MK, Karasneh JA, Lynch E, Lamey PJ, Clifford TJ. Impacts of missing upper anterior teeth on daily living. Int Dent J 2009;59:127–132. 8. Gresnigt-Bekker CO, de Jongh A, Vo G, Lie F, OosterinkWubbe FM, van Rood Y. [Satisfaction about physical appearance and teeth. Results of a nationwide study]. Ned Tijdschr Tandheelkd 2008;115:369–373. 9. MacEntee MI. Oral Healthcare and The Frail Elder: A Clinical Perspective. Wiley-Blackwell, 2011. 10. Petersen PE, Yamamoto T. Improving the oral health of older people: the approach of the WHO Global Oral Health Programme. Community Dent Oral Epidemiol 2005; 33:81–92. 11. Shimazaki Y, Soh I, Saito T, et al. Influence of dentition status on physical disability, mental impairment, and mortality in institutionalized elderly people. J Dent Res 2001;80:340–345. 12. Sparks Stein P, Steffen MJ, Smith C, et al. Serum antibodies to periodontal pathogens are a risk factor for Alzheimer’s disease. Alzheimers Dement 2012;8:196–203. 13. Miklossy J. Alzheimer’s disease – a neurospirochetosis. Analysis of the evidence following Koch’s and Hill’s criteria. J Neuroinflammation 2011;8:90. 93
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23. Australian Government. Senate Community Affairs References Committee Report on Public Dental Services. Foltyn P. Page 14, 2.45. Available at: ‘http://www.aph.gov.au/~/media/wopapub/ senate/committee/clac_ctte/completed_inquiries/1996_99/dental/ report/report_pdf.ashx’. Accessed August 2014.
16. Niesten D, van Mourik K, van der Sanden W. The impact of having natural teeth on the QoL of frail dentulous older people. A qualitative study. BMC Public Health 2012;12:839. 17. Sarin J, Balasubramaniam R, Corcoran AM, Laudenbach JM, Stoopler ET. Reducing the risk of aspiration pneumonia among elderly patients in long-term care facilities through oral health interventions. J Am Med Dir Assoc 2008;9:128–135. 18. Isaacs B. The challenge of geriatric medicine. Oxford: Oxford University Press, 1992. 19. Foltyn P. Oral Cancer: Information for Dentists. The Kinghorn Cancer Centre and St Vincent’s Hospital. Available at: http:// tkcc.org.au/wp-content/uploads/2015/02/Oral-Cancer-Informationfor-Dentists.pdf. Accessed January 2015. 20. Cancer Council Australia. Available at: http://www.cancer.org. au/about-cancer/types-of-cancer/head-and-neck-cancer.html. Accessed January 2015.
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22. Barrett B. The looming geriatric dental care crisis. J Can Dent Assoc 1998;64:623–624.
Address for correspondence: Dr Peter Foltyn Conjoint Senior Lecturer UNSW Dental Department St Vincent’s Hospital Victoria Street Darlinghurst NSW 2010 Email: [email protected]
© 2015 Australian Dental Association
