Australian Dental Journal

The official journal of the Australian Dental Association

Australian Dental Journal 2015; 60:(1 Suppl): 2–13 doi: 10.1111/adj.12279

Dental demographics and metrics of oral diseases in the ageing Australian population MS Hopcraft* *Melbourne Dental School, The University of Melbourne, Victoria, Australia.

ABSTRACT One of the biggest challenges currently facing the dental profession in Australia is the provision of quality and timely dental care to the elderly. Adults aged 65+ years are an exponentially growing section of the community with rapidly changing dental needs, thanks in part to improvements in oral health over the past 60 years that have resulted in a dramatically decreased rate of edentulism and subsequently an increased number of teeth present. This is a challenge not only for the public dental services, but also public health policy makers, private dental practitioners, professional organizations and dental education providers. It is an issue that crosses a range of dental care providers, not only dentists but also dental prosthetists and dental hygienists, whose role in the provision of dental services has been slowly growing in Australia. Furthermore, with evidence of links between oral and systemic health, this issue has significant impacts for the broader health system. Keywords: Ageing, demographics, gerondontics, oral health. Abbreviations and acronyms: OHIP = Oral Health Impact Profile; OHRQoL = oral health-related quality of life; RACFs = residential aged care facilities; SGH = salivary gland hypofunction.

BACKGROUND Although there have been significant improvements in oral health in Australia over the past 50 years, with a concomitant decrease in the rate of edentulism in older age groups, periodontal diseases are now more common, and most dentate residents have a large amount of plaque, calculus and debris accumulation present. This, combined with an increase in the number of natural teeth present in the elderly has also led to an increase in the risk of dental caries, and consequently an increase in caries prevalence. Dental diseases often cause pain and discomfort that may affect quality of life and nutrition, and co-morbidity associated with dental diseases, particularly periodontal diseases, is common. There is evidence of increased risk for aspiration pneumonia for nursing home residents with poor oral hygiene, placing a further burden on the health care system. Older people living in residential aged care facilities (RACFs) display some of the poorest oral health in Australia, and face significant barriers in their ability to access dental services.1 These barriers include poor working conditions for staff in nursing homes and a lack of available dental staff to 2

provide care. They have long been identified as a subpopulation at greater risk of developing dental diseases, through a combination of difficulties in accessing appropriate dental services, affordability of dental services, cognitive and physical impairments affecting the ability to maintain satisfactory oral hygiene, dependence on others to provide oral hygiene, polypharmacy and compromised medical health. Population projections from the Australian Bureau of Statistics show that while older people aged 65+ years comprised only 13.0% (2.60 million) of the population in 2004, by 2012 this was estimated to be 14.4% (3.34 million), and in 2023 this will increase to 16.8% (4.58 million). By 2061, it is estimated that 22.4% of Australians will be aged over 65 years (9.0 million).2 There will likewise be significant increases in the proportion of people aged over 85 years, from 1.5% (295 000) in 2004 to 420 300 in 2012, and up to 5.0% of the population (1.9 million) in 2061. Life expectancy for people born in 2009–2011 is now 79.8 for males, and 84.2 for females.2 Over the next 40 years, there will be a dramatic increase in both the proportion and absolute numbers of elderly Australians. © 2015 Australian Dental Association

Dental demographics and metrics of oral diseases At 30 June 2011, there were 2760 facilities providing 185 482 residential aged care places across Australia, an increase from 166 291 places in 2006.3 For every 1000 people aged 65+ years, there were 58 living in residential aged care. It has been estimated that the probability that older adults aged 65+ years will require permanent residential care at some point in their life is 0.3, and this doubles for adults aged 80+ years.4 In 2011, the mean length of stay in residential aged care was 145.7 weeks, with 38.9% of residents having stays of longer than three years.3 There has been an increase in the complete length of stay in permanent RACFs from 131.3 weeks in 1999.5 These increasing trends in the length of stay in residential aged care are expected to continue, and public dental health policy planning must account for people living in RACFs for three or more years in the future, and have in place appropriate oral health services to cater for these residents. There are significant implications associated with an increase in the length of time that people have been living in residential care. Improvements in medical knowledge and technology have led to this increase in life expectancy, particularly in residential care, but this improved life expectancy increases the cost, both to the individual and also to society. There are also associated endof-life impacts, particularly related to quality of life, for residents living extending periods in residential aged care. Australia’s National Oral Health Plan 2004–2013 identified older people as one of seven key action areas to promote and improve oral health.6 Short-medium term goals where action was recommended over 2–5 years to address these problems included: (1) ensuring that oral screening is carried out by an oral health professional on admission to RACFs and on a regular basis; (2) the development of a simple but practical oral health care plan as part of the overall care plan for every person in a residential aged care facility; (3) support for RACFs to have the flexibility to implement the oral health component of the overall care plan including maintenance of oral hygiene and timely dental treatment where needed; (4) making affordable portable dental equipment available to public and private oral health providers to enable them to treat older people in their homes and in RACFs; and (5) requiring RACFs of an agreed size to set aside a small dedicated area for the provision of a range of simple primary health services including oral health services. More than a decade after the release of the plan very few of these actions have been implemented. © 2015 Australian Dental Association

Dental services for aged care residents should focus primarily on prevention, periodontal health and oral hygiene care provision. Chalmers identified three major components of oral health care for residents of aged care facilities: (1) oral health assessment at baseline/admission and on a regular basis; (2) regular oral hygiene care provision and ongoing practical carer support; and (3) a range of creative dental treatment services in dental clinics, people’s homes and residential care.7 Dental care is particularly important for residents of aged care facilities, since oral diseases tend to be cumulative and become more complex with time. Institutionalized older adults often have cognitive and physical impairments that affect their ability to maintain oral hygiene, and are dependent on others for the daily maintenance of their mouths. They are also often medically compromised and taking a large number of medications that may reduce salivary flow and increase the risk of dental caries. Oral problems have a negative affect on quality of life, and problems with the teeth and mouth can affect nutrition, which in turn can affect general health. There is a growing body of evidence that links poor periodontal health with a range of medical problems, including cardiovascular disease, atherosclerosis and stroke. Aspiration pneumonia and bacteraemias can also be a significant problem for residents with poor oral health. A common finding for residents of aged care facilities is poor oral hygiene with a high accumulation of plaque and calculus on residents’ teeth and dentures, since carers experienced difficulty in performing regular oral hygiene care for residents.8 Therefore, access to dental care should be considered an integral component of the overall well-being of residents. Edentulism and tooth loss Edentulism is a somewhat crude measure of oral health, and is generally a reflection of past dental disease experience. Tooth loss usually occurs because of extensive dental caries, but periodontal disease, and less commonly trauma and poor alignment, may also result in tooth loss.9 Tooth loss due to caries tends to occur earlier in the life course, and periodontal disease becomes more important later in life. Data from the National Survey of Adult Oral Health in Australia in 2004–06 found that 9.8% of Australian adults aged 55–64 years, 20.3% of those aged 65–74 years and 35.7% of those aged 75+ years were edentulous.9 Edentulism is related to the level of education, eligibility for public dental care and private 3

MS Hopcraft dental insurance, in much the same way that dental caries has been shown to have a strong socio-economic gradient. These current rates of edentulism are significantly lower than those reported in the 1987–88 National Oral Health Survey of Australia, where 27.8% of adults aged 55–64 years, 42.7% of those aged 65–74 years and 63.1% of those aged 75+ years were edentulous.9 The key finding from the analysis of these two national surveys is that rates of edentulism within birth cohorts did not alter substantially over the 17year time period between surveys. The prevalence of edentulism for Australian adults born between 1933– 1949 in 1987–1988 (when they were aged 39– 55 years) was 12.3%, and in 2004–2006 (when they were aged 56–72 years) was 14.2%, and for people born between 1916–1932 the prevalence in 1987– 1988 was 32.6% and in 2004–2006 was 33.0%. These historically high rates of edentulism in older populations are essentially a function of birth cohorts, and reinforce the fact that edentulism is not an inevitable consequence of ageing. In Australia, complete tooth loss may well be considered an historical event, and projections from these studies suggest that less than 3% of the Australian population will be edentulous by 2021, decreasing to approximately 1% by 2041. As a result of this decrease in the rate of edentulism, there has been an increase in the number of natural teeth present in older Australians. While there is no consensus on either the optimal or minimum number of teeth, it is generally considered that 20 natural teeth is the minimum requirement for satisfactory function and aesthetics, and adults with less than 20 natural teeth are more likely to report a lower oral health-related quality of life.10–12 Rather than simply the number of teeth present, some researchers argue that it is the number of occluding pairs of teeth which is important, since this provides a more useful functional definition. Six occluding pairs of teeth are considered to be the minimum requirement for adequate function from a nutritional perspective.13 Kayser was the first to advocate the concept of the shortened dental arch, suggesting that a complete dentition was not necessary for adequate function or the prevention of temporomandibular disorders.14 Essentially, it has been demonstrated that there are no clinically significant differences between people with three to five occlusal units and complete dental arches with regard to masticatory ability, signs or symptoms of temporomandibular disorder, migration of remaining teeth, periodontal support and oral comfort.15 The shortened dental arch concept has important implications for dental treatment planning, since it is not always necessary to provide dental prostheses to replace missing teeth and maintain a complete dental arch. 4

In 2004–2006, people aged 55–74 years had on average 10.2 missing teeth and 3.6 teeth replaced, while people aged 75+ years had a mean 14.1 teeth missing for any reason and 7.1 teeth replaced by prostheses. Denture wear is common amongst older Australians, with 29.2% of dentate adults aged 55– 64 years, 48.0% of those aged 65–74 years and 61.2% of those aged 75+ years wearing a denture to replace missing teeth where some teeth remained.9 There has been a substantial decline in denture wear for younger adults over the past 17 years, with less of a decline in the older age groups. There were 52.5% of adults aged 55–64 years, 65.0% of those aged 65– 74 years and 78.0% of those aged 75+ years wearing a denture in 1987–1988.9 The prevalence of edentulism in Australia compares favourably with many other countries. In the United Kingdom and the Republic of Ireland, 46% and 48% respectively of the population aged 65+ years were edentulous in the last decade.16,17 A review of edentulism in Europe found a prevalence of 30–60% for people aged 65+ years across six countries in the 1980s.18 Even in countries with similar economic and social conditions, edentulism rates varied significantly, with the prevalence of edentulism amongst 75-yearold people ranging from 27% in Sweden, 45% in Denmark and 58% in Finland in the 1990s.19 Mojon et al. found that the prevalence of edentulism across Europe was not associated with a country’s economic situation or the number of dentists per capita.20 Many earlier studies reported a higher prevalence of edentulism amongst females, but this difference has tended to decrease over time in many countries.18 In a study on the 10-year incidence of tooth loss in Sweden for adults aged 55, 65 and 75 years at baseline, it was found that 48% of subjects lost no teeth over the 10-year period of study, with only 13% losing two or more teeth.21 Dental caries was the main reason for tooth loss, accounting for 60% of all cases of extraction in this population. Studies conducted in the 1970s and 1980s reported edentulism rates of 80–90% for residents of aged care facilities in South Australia, decreasing to around two-thirds of residents by the late 1990s.1,22,23 A recent study in Perth in 2002 found that 53% of residents in both high and low care facilities were edentulous, and this was mirrored in a Melbourne study in 2006, where 46.1% of residents were edentulous.24,25 The mean number of teeth present for dentate residents ranged from 11.9 in the Adelaide study in 1998, to 12.1 in the Perth study in 2002 and 14.4 in the Melbourne study in 2006. Similar rates of edentulism have been found internationally, with 42.0–65.9% of nursing home residents in the United Kingdom, Croatia and Finland showing complete tooth loss in studies conducted in the © 2015 Australian Dental Association

Dental demographics and metrics of oral diseases 2000s.18 Remaining teeth for dentate residents in these studies ranged from 11.7 in the United Kingdom to 21.1 in Croatia. A study of Norwegian elderly residents of nursing homes found that edentulism declined from 71% in 1988 to 43% in 2004, and the mean number of teeth in dentate residents increased from 10.7 to 14.6 over the same time period.26 A recent study of French nursing home residents found the rate of complete tooth loss was only 26.9%, with 32.5% of people aged 65–71 years and 32.4% of people aged 72+ years having 20 or more natural teeth.27 There are a number of consequences to these declining rates of edentulism and increasing numbers of natural teeth for residents of aged care facilities. Joshi et al. described dentistry as achieving a kind of adverse ‘consequence of success’, with improvements in tooth retention in a growing ageing population leading to more teeth at risk and therefore perversely a higher prevalence of dental caries and periodontal diseases.28 Older people with more teeth also had more dental visits, so yet another consequence of this success is an increased demand for dental services and a further strain on the dental system. Tooth loss is associated with a reduction in both measured and perceived chewing function, and may impact on nutrition and systemic health.29–31 Thus, the number of teeth present and the ability to maintain a functioning dentition are important factors for residents of aged care facilities. Compromised nutrition as a result of poor chewing capacity can impact adversely on systemic health. Continued tooth loss whilst in residential care can also be problematic, since the elderly (particularly those with cognitive impairment) may have difficulty adapting to new dental prostheses to replace missing teeth. Residents of aged care facilities now have more teeth at risk of dental disease, including dental caries and periodontal diseases than in the previous 30–40 years, and this has important implications for the provision of dental services to this section of the community. With an increasing number of older adults moving into residential care in a partially dentate state, the treatment planning and decision-making process for dental professionals becomes more complex. Treatment decisions based on maintaining an adequate number of occluding pairs of teeth or a shortened dental arch are important for ensuring sufficient functional capacity. Equally as important, the need for daily oral hygiene care becomes more paramount, with the consequences of neglect including an increased risk of dental caries and periodontal disease, as well as a greater risk for systemic sequelae due to increased plaque and debris present in the oral cavity. This can be problematic for the elderly who may have physical impairments that may hamper their ability to maintain their own oral hygiene, and also for cogni© 2015 Australian Dental Association

tively impaired residents who may be dependent on others for the provision of daily oral hygiene care. Caries There has been a significant decline in dental caries experience in Australian adults over the past 30 or more years, although this decline has been greatest in younger adults compared with older adults. Data from the national adult oral health surveys in Australia show that mean DMFT for coronal tooth surfaces has declined between 1987–1988 and 2004–2006, from 25.1 to 24.3 for people aged 75+ years, from 24.0 to 23.3 for people aged 65–74 years and from 22.4 to 21.8 for people aged 55–64 years.9 For people aged 35–44 years, mean DMFT scores have decreased 36.7% and for people aged 45–54 years, there has been a decrease of 8.3% over the same time period. For the older adults, there has been a significant change in the pattern of caries experience expressed by the DMFT index, with large decreases in the number of missing teeth being effectively offset by increases in the number of filled teeth. People aged 55+ years had an average of 0.4 untreated decayed teeth present in 2004–2006. Another consequence of decreasing coronal caries and increasing tooth retention in older age is the increased risk and prevalence of root caries. In the Australian population, the prevalence of untreated root caries increased with increasing age, from 7.1% for people aged 35–54 years, 12.6% for people aged 55–74 years and 17.3% for people aged 75+ years.9 In a study of Danish adults aged 85 years in 2000, 70% of participants had at least one filled root surface, and more than half had one or more root surfaces with active caries.32 About one-third of all exposed root surfaces had caries experience, and people with the most teeth had lower root caries experience than people with fewer teeth. In a sample of community dwelling independent adults aged 65+ years in Japan, 39% of subjects had at least one decayed root and 53.3% had at least one filled or decayed root.33 This study found a strong association between root caries and dry mouth and the frequency of toothbrushing. Several studies have investigated caries incidence in the elderly. An 11-year longitudinal study of coronal and root caries in a population based sample of 74 community dwelling elderly aged 65 years and older found that 93% of subjects developed one or more new surfaces of coronal caries experience during the study period, and 43% developed new root caries lesions.34 Subjects developed 1.8 surfaces of coronal caries and 0.1 surfaces of root caries experience per person per year. Twenty per cent of subjects developed 21–30 new surfaces and 19% developed 31 5

MS Hopcraft or more new surfaces of coronal caries. The mean annualized coronal caries attack rate was 2.1 surfaces per 100 surfaces, which was higher than the 18month and three-year data for the same study (1.4 and 1.2 respectively). This higher incidence could be as a result of changing diet or lifestyles with increasing age.34 The mean annualized root caries attack rate was lower at the end of the study period (0.8) than at the 18-month and three-year points (2.6 and 1.8 respectively), which may indicate that root caries is more likely to occur on newly exposed root surfaces, but over time these surfaces become more resistant to caries. A number of other studies support the findings of Hamasha et al., with mean annualized caries experience of 0.8–2.0.33–36 The annualized net root caries has been shown to range from 0.3 to 1.6 across several studies.9,35,36,38–40 Thomson found that the annualized combined coronal and root caries increment for older adults was at least as great as that for adolescents.35 This is an important finding, given that much of the focus of public dentistry in western countries has been on the prevention of oral diseases in children and adolescents. With changing population demography, it now appears entirely appropriate to focus similar attention to the prevention of oral diseases in the elderly. Although there have been significant improvements in caries experience across the broader Australian adult population, there is less available representative data for residents of aged care facilities, with most studies based on convenience samples rather than population based random samples. However, the available data suggest that dental caries is an increasingly significant problem for residents of aged care facilities, with untreated decay more frequently found amongst dentate nursing home residents than community dwelling older adults. In several recent studies of nursing homes residents in Perth, Melbourne and Adelaide, residents had on average 0.8–2.8 untreated decayed teeth.1,24,25 The mean number of untreated decayed teeth in the broader Australian population decreased from 1.3 to 1.4 for people aged 55+ years in 1987–1988 to 0.4 in 2004–2006. In the study of aged care facilities in Perth, root caries was found in 77.4% of dentate residents, with a mean 1.3 roots with untreated decay per resident. The mean number of teeth free from disease and without extreme mobility in the upper arch was only 4.7, and 7.3 in the lower arch.24 Chalmers et al. found a mean of 1.5 decayed and 1.1 filled root surfaces in dentate residents of Adelaide nursing homes in 1998, with significantly greater root caries experience in males.1 Silva et al. found a mean 5.0 decayed root surfaces for residents of Melbourne nursing homes.41 There was also a greater prevalence of root caries 6

experience for residents taking more than eight medications, and for residents who had been living in residential care for less than three years, suggesting that polypharmacy and dry mouth may be a risk factor for root caries. In a follow-up to this study of Adelaide nursing homes after 12 months, it was found that coronal caries surface incidence was 64.4% and root caries surface incidence was 48.5%.36 Residents with nutritional and eating problems had a significantly greater coronal caries surface increment than other residents. The data from a range of studies indicates that dental caries continues to be a significant problem for the elderly, and particularly those living in RACFs. There are a number of factors that are likely to contribute to this increased risk, including polypharmacy, impaired salivary function, poor oral hygiene related to cognitive and physical impairments and dependence on others for care, and poor access to dental services, particularly preventive care. Continued coronal and root caries incidence in a population with an increasing number of teeth has important implications for the demand for diagnostic, preventive and restorative dental services. Periodontal disease Loss of periodontal attachment is an important factor in tooth loss, and also increases the risk of root caries by exposing root surfaces. One of the consequences of decreasing edentulism rates is an increase in the prevalence of periodontal disease in the elderly. This is particularly a problem in the elderly institutionalized population, where maintenance of oral hygiene is often compromised by physical and cognitive impairments, and residents are dependent on others for daily oral hygiene care. The prevalence of gingivitis in the Australian adult population is reported to be 19.7%, with a slightly higher prevalence in older adults.9 People aged 55– 74 years had a prevalence of gingivitis of 21.0% and people aged 75+ years had a prevalence of 23.7%. The prevalence of periodontal disease in the Australian population, defined as at least one site with a periodontal pocket depth of 4 mm or more, was 19.8%.9 Periodontal disease prevalence was greater in older adults, with 26.0% of people aged 75+ years and 23.7% of people aged 55–74 years with one or more sites with a 4+ mm periodontal pocket, although only 1.3–1.6% of all tooth sites had a periodontal pocket depth of 4+ mm. The prevalence of gingival recession was high, with 85.7% of people aged 55–74 years and 95.2% of people aged 75+ years having at least one site with 2+ mm gingival recession. Gingival recession is a significant finding in older adults because the exposed root surface is © 2015 Australian Dental Association

Dental demographics and metrics of oral diseases more susceptible to dental caries, and therefore increases the risk for the patient. In Denmark, 35.7% of adults aged 35–44 years of age had 4–5 mm periodontal pocket depths and a further 6.4% had 6+ mm pocket depths, while for adults aged 65–74 years of age, 62.1% had 4–5 mm pockets and 20% had 6+ mm pockets in 2000–2001.37 These findings are consistent with several other studies of Danish adults that show a relatively high prevalence of severe periodontal conditions, and suggest that the periodontal health of adults in Denmark is poor in comparison to other industrialized countries. The proportion of Danish adults affected by deep periodontal pockets is approximately twice that of French and American adults of the same age. It is postulated that the high rate of periodontal disease in Denmark may be related to the high prevalence of cigarette smoking in that country.37 A recent cross-sectional study examined changes in periodontal status in 60- and 70-year-old Swedes over a period of 20 years (1973, 1983, 1993).38 The proportion of people with healthy periodontal tissues and no alveolar bone loss increased, and the proportion of people with moderate bone loss decreased between 1973 and 1983. However, the proportion of people with severe bone loss increased between 1973 and 1983, but was unchanged between 1983 and 1993, despite people in this group exhibiting a further significant increase in tooth retention.38 Periodontal disease is a common finding in residents living in aged care facilities. A study of residents in Adelaide nursing homes found that mild-moderate loss of periodontal attachment was common, but more severe disease was present in only 4.4% of residents.1 Although severe periodontal disease was not prevalent, the large amount of plaque, calculus and debris accumulation was a concern. The authors concluded that adequate oral hygiene was not being maintained for dentate residents, most likely because residents were functionally dependent, medically compromised, cognitively impaired and behaviourally difficult. In a study of residents in Perth nursing homes, 93% of dentate residents had visible plaque, 50.6% had visible supragingival calculus, 56.1% had gingival inflammation and 79.9% had gingival recession.24 Periodontal probing and clinical attachment loss were not recorded in this study. In a study of Melbourne nursing home residents in 2006, the prevalence of 4+ mm periodontal pockets was 35.6%, with 10.2% having 6+ mm pockets.42 Logistic regression found that age, gender, number of teeth present and oral hygiene were all strongly associated with the prevalence of 4+ mm periodontal pockets. © 2015 Australian Dental Association

Oral mucosal conditions Most research on the oral health of the elderly and those living in RACFs emphasize dental caries and periodontal diseases, and often do not mention diseases of the oral mucosa. Not only do oral mucosal diseases have significant problems in terms of symptoms and adverse affects for the patient, but the oral mucosa also performs an important protective function, and a decline in this protective function could expose the ageing individual to a range of pathogens and other harmful substances.43 As with dental caries and periodontal disease, a number of studies have shown that the prevalence of oral mucosal disease is higher in older people, although there are a number of factors which may influence the development of oral mucosal lesions, including trauma, medications, and oral and denture hygiene.43 The more common oral mucosal conditions include candida-induced denture stomatitis, denture-related hyperplasia, angular cheilitis and traumatic ulceration, conditions that are associated with denture wearing which is more prevalent amongst the elderly.44–47 There appears to be general agreement that denture stomatitis is the most common oral mucosal condition amongst the elderly, although it remains to be seen whether changing patterns of edentulism and complete denture wear will impact on this.48,49 Tobacco and alcohol consumption are also strongly associated with oral mucosal lesions, particularly precancerous and cancerous lesions, and the cumulative effect of these exposures means that these types of lesions are likely to be more common in the elderly. Jainkittivong et al. reported prevalence of a number of oral mucosal lesions in subjects aged over 60 years attending a dental clinic for routine examination.43 They found 15.6% of subjects with a traumatic ulcer, 7.2% with denture stomatitis, 4.8% with leukoplakia, 3.4% with angular cheilitis, 2.8% with lichen planus, 1.8% with candidiasis and 0.6% with carcinoma. Subjects who wore dentures had significantly more oral mucosal conditions than those who did not wear dentures. This study showed an increasing prevalence of oral mucosal conditions with increasing age, with a prevalence of 91.3% in the oldest age group (70+ years of age), although this was predominantly varices and fissured tongues. The prevalence of oral carcinoma did not vary with increasing age. The oldest age group also had a higher average number of oral mucosal lesions than younger subjects. Traumatic ulcers were the third most prevalent oral mucosal condition, and were found predominantly on the buccal mucosa associated with poorly fitting dentures, fractured restorations and sharp edges on worn teeth. 7

MS Hopcraft Lichen planus is a chronic inflammatory condition that may manifest in the oral cavity as reticular, papular, plaque, atrophic, erosive (ulcerative) and bullous lesions.50 Some forms may be associated with significant symptoms requiring treatment, usually in the form of topical or systemic immunosuppressive therapy. Perhaps more importantly, there is some evidence of a risk of malignant transformation in oral lichen planus. Given the length of time many residents of aged care facilities remain in residential care, early detection of oral lichen planus is important in allowing treatment and monitoring of potentially malignant lesions. A recent review of the literature found that although there were significant methodological issues in many of the epidemiological studies of oral lichen planus, the available data suggests an age-standardized prevalence of 1.27% (0.96% in males and 1.57% in females).50 Kruger et al. found that the majority (85%) of edentulous elderly in rural and remote Western Australia had oral mucosa that was not healthy (inflammation, oral lesions, ulcers or visible pathology), compared with that of dentate people (41%).51 This study did not specify the exact types of oral mucosal conditions present, but found that oral mucosal problems were predominantly related to wearing dentures. In Australia oral cancers account for approximately 2–3% of all cancer types, and approximately 1% of deaths due to cancer.52–54 There are approximately 2000 new cases of oral cancer diagnosed in Australia each year, with nearly 400 deaths attributable to oral cancer annually, and an increasing trend in the incidence of oral cancers.45 The peak age for diagnosis of tongue cancer in Australia was 60–74 years of age, while Hogan et al. reported that the mean age of diagnosis for oral cancers in Tasmania was 64 years for males and 67 years for females.46,47 The overall incidence of oral cancer in Australia represents only 1 in 10 500 people; however, the increasing incidence in the elderly, combined with the significant impact of the disease means that this represents a potentially important area of diagnosis for residents in aged care facilities. Although most of the common oral mucosal lesions tend to be benign, a small proportion is either premalignant or malignant. Therefore, periodic dental examination for the detection of these types of lesions is particularly important for the elderly population. The prevalence of premalignant oral lesions in residents of aged care facilities has been reported to be 2.5– 4.8%.53 In a study of Perth nursing home residents, 44.7% of edentulous residents had a recognizable intraoral pathological condition such as candidiasis, denture 8

hyperplasia, leukoplakia, ulceration, angular cheilitis and other soft tissue anomalies, while 32.9% of the dentate residents had an obvious oral mucosal pathology.24 Xerostomia and salivary gland hypofunction Saliva has an important protective role in oral health due to its remineralizing, antibacterial and buffering actions. It functions in protection against bacteria and fungi, transportation of nutrients and digestive enzymes, lubrication of the oral cavity and remineralization of enamel, as well as aiding in chewing, swallowing and speech. There are two important conditions relating to saliva and its impact on oral health that are often confused in the literature – salivary gland hypofunction (SGH) and xerostomia. Salivary gland hypofunction is a condition in which unstimulated or stimulated salivary flow is reduced and can also result in alterations of the chemical composition of saliva. It is generally defined as an unstimulated whole saliva flow rate of less than 0.1– 0.2 mL/min, and a stimulated whole saliva flow rate of less than 0.7 mL/min.55–57 Conversely, xerostomia is defined as the subjective perception of dry mouth.58 The two conditions can exist independently – many of those with symptoms of dry mouth do not have detectably reduced flow rates, while many with SGH are symptomless, although the perception of dry mouth is often accompanied by a reduction in salivary flow. Although it is generally accepted that ageing per se has no significant clinical impact on salivary flow rates, the prevalence of xerostomia does appear to increase with age, mainly affecting the middle-aged and elderly populations, although it is possible for a person of any age to experience it.59 With an ageing population, it is becoming increasingly common to encounter cases of xerostomia. Common findings indicate that the higher prevalence of xerostomia within elderly populations is associated with medication use, certain connective tissue and autoimmune diseases such as Sj€ ogren’s syndrome, and head and neck radiotherapy. Generally, females are also more likely to experience xerostomia. Symptoms of xerostomia include halitosis, oral soreness and burning, difficulty swallowing and talking, and altered taste. Xerostomia and SGH increase the risk of dental caries, and can contribute to periodontal diseases and oral infections such as candidiasis. Saliva has an important role in the retention of dentures, and SGH can have a significant detrimental effect on denture wearers. Oral health-related quality of life is generally poorer in people with xerostomia or SGH. The prevalence and incidence of xerostomia varies across a number of studies, but a recent systematic © 2015 Australian Dental Association

Dental demographics and metrics of oral diseases review of population based research suggests prevalence in the community of approximately 20%, although this appears to be higher in older populations and the institutionalized.60 Females also tend to report a higher prevalence than males, and Nederfors et al. found a higher prevalence of xerostomia in females, showing a dose-response relationship between the number of medications taken and an increasing prevalence of xerostomia.61 Often patients with xerostomia or SGH suck on sugary sweets or drink juices or cordials high in sugar and with a low pH to alleviate their symptoms. Acidic food and beverages (particularly citric acid) may be used to stimulate salivary flow. Some saliva substitutes also have a low pH, and this may in fact contribute to the caries process. These cariogenic or erosive behaviours are likely to contribute significantly to the high prevalence of coronal and root surface caries in residents of aged care facilities. Oral health-related quality of life Purely clinical measures of oral health such as DMFT for dental caries experience and attachment loss or bleeding on probing for periodontal disease do not take into consideration the functional and psychosocial aspects of health and disease, nor do they always accurately reflect the health status, functioning and perceived needs of individuals. Gilbert describes a model of oral health comprising five dimensions, namely oral disease and tissue damage, oral pain and discomfort, oral functional limitation, oral disadvantage and self-rated oral health.62 Oral health-related quality of life (OHRQoL) can be thought of as comprising the components of oral pain and discomfort, oral functional limitation, oral disadvantage and selfrated oral health. OHRQoL was originally measured using a 49question instrument known as the Oral Health Impact Profile (OHIP), based on Locker’s theoretical model of oral health.63 The 49 questions were based on the seven dimensions of functional limitation, physical pain, psychological discomfort, physical disability, psychological disability, social disability and handicap. A number of studies have shown that a variety of oral diseases and conditions such as missing teeth, untreated decay and periodontal disease can affect well-being.64,65 Slade developed and validated the OHIP-14, a short-form version of the 49-question instrument.63 Untreated dental caries and the number of decayed teeth do not necessarily result in impacts on quality of life.66 Dental caries has a long latent period, and is often asymptomatic in the early stages of the disease. Symptoms that would result in the reporting of oral health impacts, such as pain, discomfort, food packing © 2015 Australian Dental Association

and aesthetic concerns tend to occur later in the course of the disease. However, it is the cumulative nature of dental diseases such as dental caries and periodontal disease that may eventually lead to tooth loss, and it appears that loss of teeth resulting in functional impairment has a greater affect on quality of life. Chronic periodontal disease is generally asymptomatic, and many patients are unaware of their periodontal status. It is generally only in the latter stages of the disease that patients may become aware of problems such as tooth mobility, pain, difficulties chewing, gingival recession, dentine hypersensitivity and loss of gingival papillae. There is not a simple linear relationship between the number of deep pockets, the number of missing teeth and self-assessed oral health measures.67 For periodontal pockets, OHRQoL only appeared to be influenced when a number of teeth were affected (generalized periodontal disease), but not by the presence of a few deep periodontal pockets (localized periodontal disease). It is likely that patients with chronic generalized periodontal disease are more likely to have noticeable signs and symptoms, such as pain, discomfort and tooth mobility, thus affecting their quality of life. Certainly, patients who report symptoms such as swollen or sore gums, receding gums, loose teeth and oral malodour have a greater oral health impact than those who do not report symptoms.68 There is an association between various sociodemographic factors and OHRQoL in the elderly population, although this may vary by dentate status.69 For dentate elderly, transportation difficulties, race, income and education were associated with decrements in OHRQoL, while only race and education were important for edentulous residents. These socio-demographic variables are also known to impact on oral health. Age per se was not found to be associated with a decrement in OHRQoL. Although there are known to be significant associations between socio-demographic factors and OHRQoL in the dentate elderly, this does not mean that these factors are not equally important in the edentulous, rather that edentulous people suffer decrements in their quality of life irrespective of socio-demographic circumstances.69 There also appear to be cultural and/or ethnic differences in perceptions of OHRQoL, at least as far as country of birth is concerned.70,71 It appears that there are cultural norms that influence how individuals perceive ageing and tooth loss, which in turn determine whether they perceive impacts on quality of life. Oral health impacts caused by socio-demographic factors such as age, gender and socio-economic status are also known to be culturally sensitive, and dental anxiety is also likely to influence OHRQoL, accounting for as much as 18% of the variance in reported scores.72 9

MS Hopcraft It has long been recognized that missing teeth has an impact on various aspect of oral health, including function and aesthetics, and these factors in turn affect quality of life. It has been demonstrated that eight premolars were required for satisfactory chewing, 12 anterior teeth were necessary for speech and 12 anterior teeth plus four upper premolars were required for satisfactory aesthetics.14 Morita et al. found significant differences in the ability to function (the physical ability to perform work or other daily activities) and a range of clinical measures of tooth loss among 80-year-old community dwelling Japanese.73 There were significant differences between edentulous subjects and those with 1–9 natural teeth and 10+ natural teeth; people with 1–6 anterior occluding pairs of natural teeth had higher functioning than people with no anterior occluding pairs, and people with 1–12 posterior occluding pairs of natural teeth had higher functioning than those with no posterior occluding pairs. Tsakos et al. found that for the dentate elderly, the number of occluding pairs was significantly associated with OHRQoL, after adjusting for the effects of age, gender and education.66 People with fewer than nine occluding pairs of natural teeth were 2.6 times more likely to report oral impacts than those with nine or more pairs, and those with fewer than three occluding pairs of natural teeth in the anterior mouth were three times more likely to report oral impacts than those with three or more pairs. The OHIP-14 instrument has been used to demonstrate a linear relationship between the number of missing teeth and the number of impacts reported fairly often or very often.70 Longitudinal research found that people who experienced tooth loss over a two-year period reported an increase in the number of impacts, while people who did not experience tooth loss had effectively no change in their quality of life.74 People with 25 or more natural teeth in both the United Kingdom and Australia had significantly better OHRQoL than people with less teeth. Historically, 20–21 natural teeth has been considered the minimum threshold for a functional dentition, and this has also been linked to adequate nutrition. For edentulous older adults, the quality of dentures is associated with OHRQoL. People with dentures that had inadequate retention and poor adaptation of the fitting surface were twice as likely to report oral impacts as those with well-fitting dentures.75 For the institutionalized elderly, the subcategory of ‘functional limitation’ in measuring OHRQoL showed the greatest impairment, while the items with the highest impairment for residents were: ‘dentures not fitting properly’, ‘uncomfortable dentures’, ‘self-conscious due to teeth’, ‘avoid eating some foods’, ‘felt 10

depressed’, ‘avoid going out’ and ‘general health worsened’.76 Several studies conducted in various countries have been consistent in showing that xerostomia has a negative impact on OHRQoL in both old and young populations, in the general population as well as the institutionalized elderly. As well as impacting on oral health, xerostomia also impacts general health and psychological well-being. Early research showed that xerostomia is related to other oral symptoms that can negatively affect OHRQoL. Those with xerostomia are more likely to report other oral symptoms including a burning sensation in the mouth, an unpleasant taste, bad breath, and painful ulcers, and denture use is also affected by xerostomia. Oral dryness is related to higher reports of pain and discomfort among denture wearers.40 The physiological effects of xerostomia cause those experiencing it to change their daily behaviours such as speaking and eating. The following factors were significantly related to dry mouth: ‘prevented from eating foods you would like to eat’, ‘your enjoyment of food is less than it used to be’, ‘takes you longer to finish a meal than others’, ‘embarrassed by appearance or health of teeth or mouth’ and ‘avoid laughing or smiling’. Xerostomia was also related to the following behaviours: avoid eating with others because of problems chewing and avoid conversation with others.40 Xerostomia is so strongly associated with OHRQoL that it is believed to explain why dental status was not found to be an indicator of OHRQoL.77 Dry mouth was shown to have a major impact on OHRQoL in that Xerostomia Inventory scores were associated with all five functional and psychosocial measures used in the study. Since dental status was not implicated as an indicator of OHRQoL, xerostomia was used to explain the occurrence because it was equally prevalent among both the dentate and edentulous in this sample. Interestingly, only one-third of all participants and 40% of dentate participants expressed dissatisfaction with oral health. This may have resulted because this population expects problems with oral health and adapts to endure through them.77 It is important for oral health practitioners to recognize the importance not only of oral disease and oral health of the elderly, but also the impacts that oral disease have on well-being. Maintaining an adequate dentition for function and aesthetics is likely to have the greatest effect on quality of life, as well as managing symptoms related to dry mouth which are prevalent in the older population. Therefore, dental services must focus on preserving the maximum number of teeth possible to achieve optimum oral health and quality of life. © 2015 Australian Dental Association

Dental demographics and metrics of oral diseases CONCLUSIONS The Australian population is ageing, and these older adults are retaining more natural teeth. There is an increased risk of periodontal disease and dental caries (particularly root caries), and problems associated with the management of patients with a heavily restored dentition. Many older people, particularly those who are no longer living independently, often experience difficulties accessing dental care. Those elderly Australians living in RACFs are particularly at risk of limited access to dental care. Understanding the dental treatment needs of residents of aged care facilities and developing appropriate policies to manage these problems are essential in order to ensure that these residents are able to access dental services and maintain their oral health and quality of life. DISCLOSURE The author has no conflicts of interest to declare. REFERENCES 1. Chalmers JM, Hodge CP, Fuss JM, Spencer AJ, Carter KD. The Adelaide Dental Study of Nursing Homes 1998. AIHW cat. no. DEN 83. Adelaide: AIHW Dental Statistics and Research Unit (Dental Statistics and Research Series No. 22), 2000.

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© 2015 Australian Dental Association

Address for correspondence: Clinical Associate Professor Matthew Hopcraft Melbourne Dental School The University of Melbourne Victoria 3010 Email: [email protected]

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