Australian Dental Journal
The official journal of the Australian Dental Association
Australian Dental Journal 2015; 60:(1 Suppl): 14–19 doi: 10.1111/adj.12280
Periodontal considerations in older individuals I Darby* *Melbourne Dental School, The University of Melbourne, Victoria, Australia.
ABSTRACT In the next few years there will be a great increase in the percentage of the population aged over 65. Not only will they have more teeth than previous generations, but also a large number of implants. The increase in age is accompanied by an increase in the prevalence and incidence of periodontal diseases. In addition, there is a decrease in manual dexterity and an increase in co-morbidity and medications affecting the oral cavity. Dental care in aged care facilities can be poor and access to dental professionals difficult. This article discusses these issues. Keywords: Ageing, diabetes, non-surgical therapy, oral hygiene, peri-implantitis, periodontal disease. Abbreviations and acronyms: CPI = Community Periodontal Index; NHANES = National Health and Nutrition Survey.
INTRODUCTION As has been mentioned previously, the longer lifespan means that the teeth and supporting structures continue to be used and exposed to bacteria for much longer. This article briefly looks at the prevalence of periodontal disease in the elderly, whether the risk factors change, medical conditions of particular note, maintenance of health or management of periodontal disease and the issues thereof and, lastly, peri-implant infections. Prevalence of periodontal disease in older individuals The prevalence of periodontitis and the severity increases with greater age. From the 2004–2006 National Survey of Adult Oral Health, RobertsThomson and Do1 reported that 25% of 35–54 year olds had moderate or severe periodontitis. However, 44% of 55–74 year olds had moderate or severe periodontitis, and this increased to 61% of over 75 year olds. This is supported by World Health Organization data2 showing that in those aged 65 and over, 45% had CPI scores of 3 or more and just 7% had no symptoms. In addition, in an outer Melbourne community dental clinic setting, Darby et al.3 also noted the same trend with 43% of those aged 65 and over having CPI scores of 3 or 4. Interestingly, only 6.7% of this age group had healthy periodontal tissues. Hopcraft et al.4 reported similar levels of disease in nursing home residents with an increase up to 85 years old. This pre14
sents the issue to the dental profession on how best to manage the increasing disease burden. The risk factors for periodontal disease in this older population are no different to those for younger patients. They include age, gender, race/ethnicity, income, education and dental visits.5 The author would also like to emphasize the effects of smoking and diabetes.3,7 Darby et al.3 reported increased levels of disease in immigrants compared to those born in Australia as well as the above risk factors. Indigenous Australians have much higher levels of disease and tooth loss compared to non-Indigenous populations.8 This increase in periodontal disease does not appear to result from a diminished immune system through ageing, rather the increased length of exposure and cumulative effects of various risk factors. That said, Papapanou et al.6 found an increased rate of periodontal breakdown in over 70 year olds. The presence of periodontal disease in the elderly can have a major impact on their quality of life through swollen gums, sore gums, receding gums, loose teeth, teeth that have drifted and bad breath.9 These authors also showed a significant negative correlation between the number of teeth with probing depths of 5 mm and above and oral health-related quality of life. The number of teeth correlates positively with an individuals perceived satisfaction of their oral condition.10 Therefore, maintaining oral health in an ageing population is important not just from having a healthy mouth, but also psychological health as well. © 2015 Australian Dental Association
Periodontal considerations in older individuals The impact of systemic health The presence of periodontal disease can affect the body in two ways: dissemination of bacteria into the bloodstream and through the effect of inflammatory mechanisms.11 However, systemic diseases can also affect the oral cavity. These have been reviewed by Cullinan et al.12 in 2009. It is appropriate to discuss a number of periodontal–systemic interactions that are relevant in an ageing population. Diabetes Over the next 20 years the International Diabetes Federation has predicted a 47% increase in the number of people with diabetes in the Asia–Pacific region.13 Much of this increase is related to ageing, poor diet, obesity and sedentary lifestyle. Asians appear to be particularly at risk.14 It is becoming a major health issue with significant morbidity and mortality. The prevalence of diabetes and undiagnosed diabetes may be around 20% in older adults.15 There is a two-way relationship between diabetes and periodontal disease. Diabetics have poorer oral health, especially the longer they have been diabetic.16 More recently the effect of periodontal disease worsening glycaemic control has become known and may be related to the systemic effect of periodontal inflammation.17 Genco and Borgnakke17 summarized the analysis of NHANES I data, noting that baseline periodontal disease independently predicted diabetes. There may be a small effect of non-surgical periodontal therapy on glycaemic control of about a 0.4% reduction in glycated haemoglobin.18 Prediabetes is impaired fasting glucose or glucose intolerance as measured by elevated glycated haemoglobin or abnormally high glucose levels, but not yet frank diabetes. It is also associated with periodontal disease.17 Lalla et al.19 assessed the diabetic status of over 600 periodontal patients, finding that 4.2% were undiagnosed and 32% were prediabetic. There seems to be a much higher diabetes risk in patients with periodontal disease than those with periodontal health.20 However, diabetes risk also increases with age. In a group of severe periodontitis patients, over 7% were undiagnosed diabetics and over 55% prediabetic.21 The management of the diabetes and prediabetes may be required to improve the outcomes of periodontal therapy. In addition, poor glycaemic control is linked to progression of disease and tooth loss.22 Obesity Obesity is also increasing in the population and is defined as a BMI of 30 or greater. It is associated with a great many health issues including cardiovascular © 2015 Australian Dental Association
disease, stroke, cancer and diabetes.23 It has also been shown to increase the risk of periodontal disease.24 While obesity may reflect a poor lifestyle it is now known to be a chronic inflammatory state and may affect susceptibility for periodontal diseases.25 Metabolic syndrome Metabolic syndrome is the presence of abdominal obesity, dyslipidaemia, hyperglycaemia and hypertension.14 It increases the risk for diabetes and cardiovascular disease. In Caucasians abdominal obesity is defined as a waist circumference of over 100 cm in males and 90 cm in females. These figures are lower for Asians. Studies in Japanese populations have shown that those with metabolic syndrome have a much greater risk of periodontal disease.26,27 Using data from NHANES III, D’Aiuto et al.28 reported the prevalence of metabolic syndrome in subjects with no or mild periodontitis was 18% compared to 37% in those with severe periodontitis. From the above discussion it is quite clear that diabetes, obesity and metabolic syndrome will have a great impact not only on the prevalence and incidence of periodontal disease in an ageing population but also the dental profession with a potentially much greater disease burden to manage as well as the related poor treatment outcomes. This would suggest a multidisciplinary team approach with medical colleagues to best manage these patients. Osteoporosis Osteoporosis is a systemic disorder characterized by reduced bone–mineral density. It affects the whole skeleton and increases the risk of fracture, especially the hip. The US NHANES III data suggests that 13–18% of females and 3–6% of males have osteoporosis.29 In addition, many more have osteopenia, 37–50% of females and 28–47% of males. In a systematic review, Martinez-Maestre et al.29 showed that osteoporosis is associated with increased tooth loss and may be associated with periodontal disease although the evidence is less convincing. However, the data would indicate that a sizeable proportion of the elderly may have dental issues as a result of osteoporosis, particularly females. Polypharmacy As discussed elsewhere in this supplement by Thomson, the elderly very often take a number of different medications which can have side effects in the oral cavity, particularly xerostomia.30 These may increase the risk of periodontal disease, but may also complicate treatment and outcomes. 15
I Darby Management of periodontal diseases The non-surgical management of periodontal disease was described by Darby.31 It is effective, particularly when followed by regular maintenance. However, for the elderly that don’t have easy access to dental care or are in residential aged care facilities, control of periodontal disease becomes a problem. Residents in aged care facilities often experience difficulties in accessing dental care, particularly with transport to a dental practice, with only 11% having visited a practice in the previous 12 months.4 Also of note is that most dentists don’t undertake treatment in nursing homes, further limiting residents’ access to necessary care. Good oral hygiene is important in maintaining oral health. Poor oral hygiene contributes to the risk for periodontal disease and caries. Most people are not effective brushers and this decreases with age.32 With cognitive or motor impairment the elderly may have to rely on someone to clean their teeth for them. Powered brushes provide a better reduction in plaque and are easier to use.33 The use of toothpaste is recommended to maintain and promote periodontal health.32 The addition of chemical agents such as stannous fluoride provide greater plaque reduction than just fluoride toothpaste alone. In most people toothbrushing must be supplemented with interproximal cleaning. With increasing age and decreasing dexterity flossing becomes more difficult. Woodsticks and interdental brushes are more effective than floss in general, and are better for larger interproximal spaces and easier to use.
Aged care facilities People living in residential aged care facilities struggle to maintain good oral hygiene. Hopcraft et al.4 in their study of oral health in nursing homes showed that less than one-third of residents cleaned their own teeth twice a day, but more than half once a day. One-third of residents had some assistance and those with cognitive impairment, such a dementia, required help. When assistance was required only 30% had their teeth cleaned once or twice a week. Educating the elderly is an answer, but they may have trouble with dexterity or holding the brush. Bigger brush handles or powered brushes may help. In addition, those with cognitive impairment may not remember the instructions and, irrespective of age, all oral hygiene advice needs continued reinforcement. A solution is to educate the carers, but there seems to be a lack of appropriate education and most information comes from journals, books, AV media or in-house training by other staff.34 One-third didn’t receive any information at all. Additional barriers are no reinforcement, 16
low priority, fear of causing pain and injury, a perception that oral care does not provide significant benefits, issues with poor patient cooperation, too few staff and a lack of time. Terezakis et al.35 also noted a high rate of staff turnover. The use of family members seems to have been overlooked, but they may not be interested in looking after the resident, live too far away or might not be able to afford oral hygiene products. Hopcraft et al.34 showed that dental hygienists could assess and treat residents appropriately when compared to dentists and they may be a valuable resource for management of residents. Hospitalized individuals Oral health can deteriorate in hospital, particularly if the individual is unable to brush their teeth.35 For example, in intubated patients access for oral hygiene may be limited and, similar to aged care facilities, the ability of hospital staff to provide adequate oral hygiene may be compromised and for similar reasons. Intubation contributes to an increased incidence of hospital acquired infections, such as respiratory tract infections and ventilator associated pneumonia. Good oral hygiene can reduce the risk of these infections and prevent oral health from getting worse. A number of different devices have been suggested and include toothettes, which are small sponges on the end of a handle, gauze swabs, manual and electric toothbrushes. The toothettes and gauze can be soaked in chlorhexidine or similar solution. However, Needleman et al.36 suggested that manual removal of plaque is to be preferred and is best achieved through toothbrushing, either manual or better powered. Training all the nursing staff is an unrealistic expectation given shift patterns and the time commitment.35 In addition, some hospitals will not buy toothbrushes for inpatients. As mentioned elsewhere in this supplement, the baby boomer generation have heavily restored dentitions.37 They had a high caries rate and as a consequence have large restorations, endodontic treatment, crown and bridgework, and implants. They will have on average another 30 years to live and the management of their restored mouths will be an issue. Good oral hygiene is necessary in their care and longevity. As mentioned above oral hygiene and access to dental care can be problematic in aged care facilities and hospitals. The cost-effectiveness of periodontal management In the US in 2006 the cost of management of oral biofilm associated diseases was greater than that for heart conditions, trauma, cancer, pulmonary and mental health costs.11 Dentistry is expensive and those on a pension may not be able to afford the cost of © 2015 Australian Dental Association
Periodontal considerations in older individuals periodontal management, especially as oral health may deteriorate in later life and they then require much more treatment. Removal of the oral biofilm is paramount. Patient self-care is the most cost-effective (a)
approach to the prevention and management of periodontal disease.38 The use of toothpaste can reduce the incidence of caries, especially root surface caries. It was also suggested that the use of adjunctive antiseptics as part of the home care routine should be considered as another cost-effective measure. Modification of changeable risk factors, such as smoking, diabetes and obesity, are to be recommended. Professional removal by dental hygienists, dentists and periodontists depends on the patient’s ability to access the practice or domiciliary visits. Costs for treatment will be reflected by which type of dental practitioner provides treatment. The circumstances of treatment provision, such as in a nursing home, may limit any periodontal therapy to scaling and root planing or
(b) (a)
(c)
(b)
(d) (c)
Fig. 1 A 79-year-old male living in an aged care facility with generalized severe chronic periodontitis. (a) OPG showing widespread subgingival deposits and bone loss; (b) anterior view; (c) mirror view of right side; and (d) mirror view of left side. Clinical photos were taken after extraction of upper central incisors. © 2015 Australian Dental Association
Fig. 2 A 71-year-old male living with type II diabetes, periodontal disease, caries and 11 implant to manage. (a) OPG showing widespread bone loss; (b) anterior view with 10 mm probing depth associated with 11 implant; (c) mirror view of left side. 17
I Darby maintenance debridement. However, regular maintenance can prevent and manage periodontal disease, as shown by periodontal patients that don’t comply with their maintenance regimes and as such are an appropriate cost-effective method.39 In a situation where only basic treatment can or will be provided, then perhaps the patients should be made dentally fit prior to entering a residential aged care facility and have a periodontium that is easy to maintain. This may mean extraction of teeth with deep periodontal pockets that would otherwise be maintained in private practice. Provision of oral hygiene instruction to ensure a good standard of home care would also be part of preparing patients for nursing homes or hospital. In addition, a heavily restored dentition may be difficult and expensive to maintain in a healthy state. So some thought should be given to providing the patient a dentition that is easily maintainable and reparable when they become a resident in a home. Management of peri-implantitis Over the last two decades implant dentistry has become a fundamental part of dentistry and is increasingly the treatment of choice for replacement of missing teeth. Over the coming years more and more patients will have implants that need ongoing care as they enter retirement. The prevalence of peri-mucositis may be as high as 50% and peri-implantitis varies from less than 1% to almost 30%.40–43 The diagnosis and management was well described by Heitz-Mayfield in 2008 and has not dramatically changed.44 With the deterioration of oral health in aged care facilities it is not unreasonable to suggest that periimplant health will also suffer. Risk factors for periimplant disease may include diabetes, osteoporosis, smoking, poor oral hygiene, a history of periodontitis and compliance with maintenance appointments, which have been discussed above.45,46 Peri-mucositis can respond well to management. However, in a recent review, Heitz-Mayfield and Mombelli noted that in the treatment of peri-implantitis, although many short-term outcomes are favourable, there can be a lack of disease resolution and further progression, recurrence of the disease and implant loss.47 It is clear that in patients with dental implants, enrolment in a maintenance programme is necessary to get the best survival and success rates.48 This will be difficult for those in aged care or hospitals. Not only are implants at an increased risk of disease, they are also costly to manage.49 Although the number of disease-free years was the same as teeth, the cost of maintaining implants was greater than that of teeth. Keeping the teeth may be a more costeffective and simpler option in the long term in the elderly. 18
CONCLUSIONS Given the issues with oral health care it makes sense to render patients dentally and/or periodontally fit before they enter an aged care facility or hospital. Provision of dental treatment that is easy to maintain in the long term has to be favoured as well as retention of teeth where possible. The elderly are at high risk for further disease and oral care in aged care facilities and hospitals must be improved. This may be by encouraging more dentists to make domiciliary visits, use of dental hygienists, educating patients, carers, nurses and relatives or by lobbying the government to provide better funding. ACKNOWLEDGEMENTS This article is dedicated to Dr Rain Papli, friend and colleague, who was a keen advocate of improving oral health in aged care facilities. DISCLOSURE The author has no conflicts of interest to declare. REFERENCES 1. Roberts-Thomson KF. Oral health status. In: Slade GD, Spencer AJ, Roberts-Thomson KF, eds. Australia’s Dental Generations: The National Survey of Adult Health 2004–2006. Canberra: Australian Institute of Health and Welfare, 2007:81–142. 2. World Health Organization. The WHO Global Oral Health Data Bank. Geneva: WHO, 2007. Available at ‘http:// www.who.int/oral_health’. 3. Darby IB, Phan L, Post M. Periodontal health of dental clients in a community health setting. Aust Dent J 2012;57:486–492. 4. Hopcraft MS, Morgan MV, Satur JG, Wright FAC, Darby IB. Oral hygiene and periodontal disease in Victorian nursing homes. Gerodontology 2012;29:e220–e228. 5. Dye BA. Global periodontal disease epidemiology. Periodontol 2010 2012;58:10–25. 6. Papapanou PN, Wennstrom JL, Grondahl K. A 10-year retrospective study on periodontal disease progression. J Clin Periodontol 1989;16:403–411. 7. Do LG, Slade GD, Roberts-Thomson KF, Sanders AE. Smoking attributable periodontal disease in the Australian adult population. J Clin Periodontol 2008;35:398–404. 8. Brennan DS, Roberts-Thomson KF, Spencer AJ. Oral health of Indigenous adult public patients in Australia. Aust Dent J 2007;52:322–328. 9. Needleman I, McGrath C, Floyd P, Biddle A. Impact of oral health on the life quality of periodontal patients. J Clin Periodontol 2004;31:454–457. 10. Elias AC, Sheihan A. The relationship between satisfaction with mouth and number, position and condition of teeth: studies in Brazilian adults. J Oral Rehabil 1999;26:53–71. 11. Beikler T, Flemmig TF. Oral biofilm-associated diseases: trends and implications for quality of life, systemic health and expenditures. Periodontol 2000 2011;55:87–103. 12. Cullinan MP, Ford PJ, Seymour GJ. Periodontal disease and systemic health: current status. Aust Dent J 2009;54(Suppl 1): S62–S69. © 2015 Australian Dental Association
Periodontal considerations in older individuals 13. International Diabetes Federation. Diabetes Atlas. 4th edn. Brussels: IDF, 2009. 14. Corbet EF, Leung WK. Epidemiology of periodontitis in the Asia and Oceania regions. Periodontol 2000 2011;56:25–64. 15. Meneilly GS, Tessier D. Diabetes in elderly adults. J Gerontol A Biol Sci Med Sci 2001;56:5–13. 16. Australian Research Centre for Population Oral Health. The relationship between diabetes and oral health among Australian adults. Aust Dent J 2008;53:93–96. 17. Genco RJ, Borgnakke WS. Risk factors for periodontal disease. Periodontol 2000 2013;62:59–94. 18. Simpson TC, Needleman I, Wild SH, Moles DR, Mills EJ. Treatment of periodontal disease in people with diabetes. Cochrane Database Syst Rev 2010;5:CD004714. 19. Lalla E, Kunzel C, Burkett S, Cheng B, Lamster IB. Identification of unrecognised diabetes and pre-diabetes in a dental setting. J Dent Res 2011;90:855–860. 20. Lee M, Xia Y, Ng S, Whang A, Moon B, Ngo L, Darby IB. Diabetes risk inpatients with or without periodontitis. Periodontol 2014;32:5–10. 21. Zhang DH, Yuan QN, Zabala PM, Zhang F, Ngo L, Darby IB. Diabetic and cardiovascular risk in patients diagnosed with periodontitis. Aust Dent J 2014 Nov 20 doi: 10.1111/adj.12253 [Epub ahead of print]. 22. Costa FO, Coat LOM, Lages EJP, et al. Progression of periodontitis and tooth loss associated with glycemic control in individuals undergoing periodontal maintenance therapy: a 5-year follow-up study. J Periodontol 2013;84:595–605. 23. Kopelman P. Health risks associated with overweight and obesity. Obes Rev 2007;8(Suppl):13–17. 24. Pischon N, Heng N, Bernimoulin JP, Kleber BM, Willich SN, Pischon T. Obesity, inflammation, and periodontal disease. J Dent Res 2007;86:400–409. 25. Kershaw EE, Flier JS. Adipose tissue as an endocrine organ. J Clin Endocrinol Metab 2004;89:2548–2556. 26. Shimazaki Y, Saito T, Yonemoto K, Kiyahara Y, Iida M, Yamashita Y. Relationship of metabolic syndrome to periodontal disease in Japanese women: the Hisayama Study. J Dent Res 2007;86:271–275. 27. Morita T, Ogawa Y, Takada K, et al. Association between periodontal disease and metabolic syndrome. J Public Health Dent 2009;69:248–253. 28. D’Auito F, Sabbah W, Netuveli G, et al. Association of the metabolic syndrome with severe periodontitis in a large US population-based survey. J Clin Endocrinol Metab 2008; 93:3989–3994. 29. Martinez-Maestre MA, Gonzalez-Cejudo C, Machuca G, Torrejon R, Castelo-Branco C. Periodontitis and osteoporosis: a systematic review. Climateric 2010;13:523–529.
35. Terezakis E, Needleman I, Kumar N, Moles D, Agudo E. The impact of hospitalization on oral health: a systematic review. J Clin Periodontol 2011;38:628–636. 36. Needleman IG, Hirsch NP, Leemans M, et al. Randomized controlled trial of toothbrushing to reduce ventilator-associated pneumonia pathogens and dental plaque in a critical care unit. J Clin Periodontol 2011;38:246–252. 37. Hopcraft MS. Dental demographics and metrics of oral diseases in the ageing Australian population. Aust Dent J 2015;60(1 Suppl):2–13. 38. Slots J. Low-cost periodontal therapy. Periodontol 2000 2012;60:110–137. 39. Gjermo PE, Grytten J. Cost-effectiveness of various treatment modalities for adult chronic periodontitis. Periodontol 2000 2009;51:269–275. 40. Berglundh T, Persson L, Klinge B. A systematic review of the incidence of biological and technical complications in implant dentistry reported in prospective longitudinal studies of at least 5 years. J Clin Periodontol 2002;29(Suppl 3):197–212. 41. Rinke S, Ohl S, Ziebolz D, Lange K, Eickholz P. Prevalence of periimplant disease in partially edentulous patients: a practicebased cross-sectional study. Clin Oral Implants Res 2011;22: 826–833. 42. Roos-Jans aker AM, Lindahl C, Renvert H, Renvert S. Nine- to fourteen-year follow-up of implant treatment. Part II: presence of peri-implant lesions. J Clin Periodontol 2006;33:290–295. 43. Fransson C, Lekholm U, Jemt T, Berglundh T. Prevalence of subjects with progressive bone loss at implants. Clin Oral Implants Res 2005;16:440–446. 44. Heitz-Mayfield LJA. Diagnosis and management of peri-implant diseases. Aust Dent J 2008;53(Supp 1):S43–S48. 45. Cochran D, Schou S, Heitz-Mayfield LJA, Bornstein MM, Salvi GE, Martin WC. Consensus statements and recommended clinical procedures regarding risk factors in implant therapy. Int J Oral Maxillofac Implants 2009;24(Suppl):86–89. 46. Costa FO, Takenaka-Martinez S, Cota LOM, Ferreira SD, Silva GLM, Costa JE. Peri-implant disease in subjects with and without preventive maintenance: a 5-year follow-up. J Clin Periodontol 2012;39:173–181. 47. Heitz-Mayfield LJA, Mombelli A. The therapy of peri-implantitis: a systematic review. Int J Oral Maxillofac Implants 2014;29 (Suppl):325–345. 48. Salvi GE, Zitzmann NU. The effects of anti-infective preventive measures on the occurrence of biologic implant complications and implant loss: a systematic review. Int J Oral Maxillofac Implants 2014;29(Suppl):292–307. 49. Fardal Ø, Grytten J. A comparison of teeth and implants during maintenance therapy in terms of the number of disease-free years and costs – an in vivo internal control study. J Clin Periodontol 2013;40:645–651.
30. Thomson WM. Dry mouth and older people. Aust Dent J 2015;60(1 Suppl):54–63. 31. Darby I. Non-surgical management of periodontal disease. Aust Dent J 2009;54(Suppl 1):S86–S95. 32. Van der Weijden F, Slot DE. Oral hygiene in the prevention of periodontal diseases: the evidence. Periodontol 2000 2011;55:104–123. 33. Deery C, Heanue M, Deacon S, et al. The effectiveness of manual versus powered toothbrushes for dental health: a systematic review. J Dent 2004;32:197–211. 34. Hopcraft MS, Morgan MV, Satur JS, Wright FAC. Dental service provision in Victorian residential aged care facilities. Aust Dent J 2008;53:239–245.
© 2015 Australian Dental Association
Address for correspondence: Professor Ivan Darby Periodontics Melbourne Dental School The University of Melbourne 720 Swanston Street Parkville VIC 3010 Email: [email protected]
19
The official journal of the Australian Dental Association
Australian Dental Journal 2015; 60:(1 Suppl): 14–19 doi: 10.1111/adj.12280
Periodontal considerations in older individuals I Darby* *Melbourne Dental School, The University of Melbourne, Victoria, Australia.
ABSTRACT In the next few years there will be a great increase in the percentage of the population aged over 65. Not only will they have more teeth than previous generations, but also a large number of implants. The increase in age is accompanied by an increase in the prevalence and incidence of periodontal diseases. In addition, there is a decrease in manual dexterity and an increase in co-morbidity and medications affecting the oral cavity. Dental care in aged care facilities can be poor and access to dental professionals difficult. This article discusses these issues. Keywords: Ageing, diabetes, non-surgical therapy, oral hygiene, peri-implantitis, periodontal disease. Abbreviations and acronyms: CPI = Community Periodontal Index; NHANES = National Health and Nutrition Survey.
INTRODUCTION As has been mentioned previously, the longer lifespan means that the teeth and supporting structures continue to be used and exposed to bacteria for much longer. This article briefly looks at the prevalence of periodontal disease in the elderly, whether the risk factors change, medical conditions of particular note, maintenance of health or management of periodontal disease and the issues thereof and, lastly, peri-implant infections. Prevalence of periodontal disease in older individuals The prevalence of periodontitis and the severity increases with greater age. From the 2004–2006 National Survey of Adult Oral Health, RobertsThomson and Do1 reported that 25% of 35–54 year olds had moderate or severe periodontitis. However, 44% of 55–74 year olds had moderate or severe periodontitis, and this increased to 61% of over 75 year olds. This is supported by World Health Organization data2 showing that in those aged 65 and over, 45% had CPI scores of 3 or more and just 7% had no symptoms. In addition, in an outer Melbourne community dental clinic setting, Darby et al.3 also noted the same trend with 43% of those aged 65 and over having CPI scores of 3 or 4. Interestingly, only 6.7% of this age group had healthy periodontal tissues. Hopcraft et al.4 reported similar levels of disease in nursing home residents with an increase up to 85 years old. This pre14
sents the issue to the dental profession on how best to manage the increasing disease burden. The risk factors for periodontal disease in this older population are no different to those for younger patients. They include age, gender, race/ethnicity, income, education and dental visits.5 The author would also like to emphasize the effects of smoking and diabetes.3,7 Darby et al.3 reported increased levels of disease in immigrants compared to those born in Australia as well as the above risk factors. Indigenous Australians have much higher levels of disease and tooth loss compared to non-Indigenous populations.8 This increase in periodontal disease does not appear to result from a diminished immune system through ageing, rather the increased length of exposure and cumulative effects of various risk factors. That said, Papapanou et al.6 found an increased rate of periodontal breakdown in over 70 year olds. The presence of periodontal disease in the elderly can have a major impact on their quality of life through swollen gums, sore gums, receding gums, loose teeth, teeth that have drifted and bad breath.9 These authors also showed a significant negative correlation between the number of teeth with probing depths of 5 mm and above and oral health-related quality of life. The number of teeth correlates positively with an individuals perceived satisfaction of their oral condition.10 Therefore, maintaining oral health in an ageing population is important not just from having a healthy mouth, but also psychological health as well. © 2015 Australian Dental Association
Periodontal considerations in older individuals The impact of systemic health The presence of periodontal disease can affect the body in two ways: dissemination of bacteria into the bloodstream and through the effect of inflammatory mechanisms.11 However, systemic diseases can also affect the oral cavity. These have been reviewed by Cullinan et al.12 in 2009. It is appropriate to discuss a number of periodontal–systemic interactions that are relevant in an ageing population. Diabetes Over the next 20 years the International Diabetes Federation has predicted a 47% increase in the number of people with diabetes in the Asia–Pacific region.13 Much of this increase is related to ageing, poor diet, obesity and sedentary lifestyle. Asians appear to be particularly at risk.14 It is becoming a major health issue with significant morbidity and mortality. The prevalence of diabetes and undiagnosed diabetes may be around 20% in older adults.15 There is a two-way relationship between diabetes and periodontal disease. Diabetics have poorer oral health, especially the longer they have been diabetic.16 More recently the effect of periodontal disease worsening glycaemic control has become known and may be related to the systemic effect of periodontal inflammation.17 Genco and Borgnakke17 summarized the analysis of NHANES I data, noting that baseline periodontal disease independently predicted diabetes. There may be a small effect of non-surgical periodontal therapy on glycaemic control of about a 0.4% reduction in glycated haemoglobin.18 Prediabetes is impaired fasting glucose or glucose intolerance as measured by elevated glycated haemoglobin or abnormally high glucose levels, but not yet frank diabetes. It is also associated with periodontal disease.17 Lalla et al.19 assessed the diabetic status of over 600 periodontal patients, finding that 4.2% were undiagnosed and 32% were prediabetic. There seems to be a much higher diabetes risk in patients with periodontal disease than those with periodontal health.20 However, diabetes risk also increases with age. In a group of severe periodontitis patients, over 7% were undiagnosed diabetics and over 55% prediabetic.21 The management of the diabetes and prediabetes may be required to improve the outcomes of periodontal therapy. In addition, poor glycaemic control is linked to progression of disease and tooth loss.22 Obesity Obesity is also increasing in the population and is defined as a BMI of 30 or greater. It is associated with a great many health issues including cardiovascular © 2015 Australian Dental Association
disease, stroke, cancer and diabetes.23 It has also been shown to increase the risk of periodontal disease.24 While obesity may reflect a poor lifestyle it is now known to be a chronic inflammatory state and may affect susceptibility for periodontal diseases.25 Metabolic syndrome Metabolic syndrome is the presence of abdominal obesity, dyslipidaemia, hyperglycaemia and hypertension.14 It increases the risk for diabetes and cardiovascular disease. In Caucasians abdominal obesity is defined as a waist circumference of over 100 cm in males and 90 cm in females. These figures are lower for Asians. Studies in Japanese populations have shown that those with metabolic syndrome have a much greater risk of periodontal disease.26,27 Using data from NHANES III, D’Aiuto et al.28 reported the prevalence of metabolic syndrome in subjects with no or mild periodontitis was 18% compared to 37% in those with severe periodontitis. From the above discussion it is quite clear that diabetes, obesity and metabolic syndrome will have a great impact not only on the prevalence and incidence of periodontal disease in an ageing population but also the dental profession with a potentially much greater disease burden to manage as well as the related poor treatment outcomes. This would suggest a multidisciplinary team approach with medical colleagues to best manage these patients. Osteoporosis Osteoporosis is a systemic disorder characterized by reduced bone–mineral density. It affects the whole skeleton and increases the risk of fracture, especially the hip. The US NHANES III data suggests that 13–18% of females and 3–6% of males have osteoporosis.29 In addition, many more have osteopenia, 37–50% of females and 28–47% of males. In a systematic review, Martinez-Maestre et al.29 showed that osteoporosis is associated with increased tooth loss and may be associated with periodontal disease although the evidence is less convincing. However, the data would indicate that a sizeable proportion of the elderly may have dental issues as a result of osteoporosis, particularly females. Polypharmacy As discussed elsewhere in this supplement by Thomson, the elderly very often take a number of different medications which can have side effects in the oral cavity, particularly xerostomia.30 These may increase the risk of periodontal disease, but may also complicate treatment and outcomes. 15
I Darby Management of periodontal diseases The non-surgical management of periodontal disease was described by Darby.31 It is effective, particularly when followed by regular maintenance. However, for the elderly that don’t have easy access to dental care or are in residential aged care facilities, control of periodontal disease becomes a problem. Residents in aged care facilities often experience difficulties in accessing dental care, particularly with transport to a dental practice, with only 11% having visited a practice in the previous 12 months.4 Also of note is that most dentists don’t undertake treatment in nursing homes, further limiting residents’ access to necessary care. Good oral hygiene is important in maintaining oral health. Poor oral hygiene contributes to the risk for periodontal disease and caries. Most people are not effective brushers and this decreases with age.32 With cognitive or motor impairment the elderly may have to rely on someone to clean their teeth for them. Powered brushes provide a better reduction in plaque and are easier to use.33 The use of toothpaste is recommended to maintain and promote periodontal health.32 The addition of chemical agents such as stannous fluoride provide greater plaque reduction than just fluoride toothpaste alone. In most people toothbrushing must be supplemented with interproximal cleaning. With increasing age and decreasing dexterity flossing becomes more difficult. Woodsticks and interdental brushes are more effective than floss in general, and are better for larger interproximal spaces and easier to use.
Aged care facilities People living in residential aged care facilities struggle to maintain good oral hygiene. Hopcraft et al.4 in their study of oral health in nursing homes showed that less than one-third of residents cleaned their own teeth twice a day, but more than half once a day. One-third of residents had some assistance and those with cognitive impairment, such a dementia, required help. When assistance was required only 30% had their teeth cleaned once or twice a week. Educating the elderly is an answer, but they may have trouble with dexterity or holding the brush. Bigger brush handles or powered brushes may help. In addition, those with cognitive impairment may not remember the instructions and, irrespective of age, all oral hygiene advice needs continued reinforcement. A solution is to educate the carers, but there seems to be a lack of appropriate education and most information comes from journals, books, AV media or in-house training by other staff.34 One-third didn’t receive any information at all. Additional barriers are no reinforcement, 16
low priority, fear of causing pain and injury, a perception that oral care does not provide significant benefits, issues with poor patient cooperation, too few staff and a lack of time. Terezakis et al.35 also noted a high rate of staff turnover. The use of family members seems to have been overlooked, but they may not be interested in looking after the resident, live too far away or might not be able to afford oral hygiene products. Hopcraft et al.34 showed that dental hygienists could assess and treat residents appropriately when compared to dentists and they may be a valuable resource for management of residents. Hospitalized individuals Oral health can deteriorate in hospital, particularly if the individual is unable to brush their teeth.35 For example, in intubated patients access for oral hygiene may be limited and, similar to aged care facilities, the ability of hospital staff to provide adequate oral hygiene may be compromised and for similar reasons. Intubation contributes to an increased incidence of hospital acquired infections, such as respiratory tract infections and ventilator associated pneumonia. Good oral hygiene can reduce the risk of these infections and prevent oral health from getting worse. A number of different devices have been suggested and include toothettes, which are small sponges on the end of a handle, gauze swabs, manual and electric toothbrushes. The toothettes and gauze can be soaked in chlorhexidine or similar solution. However, Needleman et al.36 suggested that manual removal of plaque is to be preferred and is best achieved through toothbrushing, either manual or better powered. Training all the nursing staff is an unrealistic expectation given shift patterns and the time commitment.35 In addition, some hospitals will not buy toothbrushes for inpatients. As mentioned elsewhere in this supplement, the baby boomer generation have heavily restored dentitions.37 They had a high caries rate and as a consequence have large restorations, endodontic treatment, crown and bridgework, and implants. They will have on average another 30 years to live and the management of their restored mouths will be an issue. Good oral hygiene is necessary in their care and longevity. As mentioned above oral hygiene and access to dental care can be problematic in aged care facilities and hospitals. The cost-effectiveness of periodontal management In the US in 2006 the cost of management of oral biofilm associated diseases was greater than that for heart conditions, trauma, cancer, pulmonary and mental health costs.11 Dentistry is expensive and those on a pension may not be able to afford the cost of © 2015 Australian Dental Association
Periodontal considerations in older individuals periodontal management, especially as oral health may deteriorate in later life and they then require much more treatment. Removal of the oral biofilm is paramount. Patient self-care is the most cost-effective (a)
approach to the prevention and management of periodontal disease.38 The use of toothpaste can reduce the incidence of caries, especially root surface caries. It was also suggested that the use of adjunctive antiseptics as part of the home care routine should be considered as another cost-effective measure. Modification of changeable risk factors, such as smoking, diabetes and obesity, are to be recommended. Professional removal by dental hygienists, dentists and periodontists depends on the patient’s ability to access the practice or domiciliary visits. Costs for treatment will be reflected by which type of dental practitioner provides treatment. The circumstances of treatment provision, such as in a nursing home, may limit any periodontal therapy to scaling and root planing or
(b) (a)
(c)
(b)
(d) (c)
Fig. 1 A 79-year-old male living in an aged care facility with generalized severe chronic periodontitis. (a) OPG showing widespread subgingival deposits and bone loss; (b) anterior view; (c) mirror view of right side; and (d) mirror view of left side. Clinical photos were taken after extraction of upper central incisors. © 2015 Australian Dental Association
Fig. 2 A 71-year-old male living with type II diabetes, periodontal disease, caries and 11 implant to manage. (a) OPG showing widespread bone loss; (b) anterior view with 10 mm probing depth associated with 11 implant; (c) mirror view of left side. 17
I Darby maintenance debridement. However, regular maintenance can prevent and manage periodontal disease, as shown by periodontal patients that don’t comply with their maintenance regimes and as such are an appropriate cost-effective method.39 In a situation where only basic treatment can or will be provided, then perhaps the patients should be made dentally fit prior to entering a residential aged care facility and have a periodontium that is easy to maintain. This may mean extraction of teeth with deep periodontal pockets that would otherwise be maintained in private practice. Provision of oral hygiene instruction to ensure a good standard of home care would also be part of preparing patients for nursing homes or hospital. In addition, a heavily restored dentition may be difficult and expensive to maintain in a healthy state. So some thought should be given to providing the patient a dentition that is easily maintainable and reparable when they become a resident in a home. Management of peri-implantitis Over the last two decades implant dentistry has become a fundamental part of dentistry and is increasingly the treatment of choice for replacement of missing teeth. Over the coming years more and more patients will have implants that need ongoing care as they enter retirement. The prevalence of peri-mucositis may be as high as 50% and peri-implantitis varies from less than 1% to almost 30%.40–43 The diagnosis and management was well described by Heitz-Mayfield in 2008 and has not dramatically changed.44 With the deterioration of oral health in aged care facilities it is not unreasonable to suggest that periimplant health will also suffer. Risk factors for periimplant disease may include diabetes, osteoporosis, smoking, poor oral hygiene, a history of periodontitis and compliance with maintenance appointments, which have been discussed above.45,46 Peri-mucositis can respond well to management. However, in a recent review, Heitz-Mayfield and Mombelli noted that in the treatment of peri-implantitis, although many short-term outcomes are favourable, there can be a lack of disease resolution and further progression, recurrence of the disease and implant loss.47 It is clear that in patients with dental implants, enrolment in a maintenance programme is necessary to get the best survival and success rates.48 This will be difficult for those in aged care or hospitals. Not only are implants at an increased risk of disease, they are also costly to manage.49 Although the number of disease-free years was the same as teeth, the cost of maintaining implants was greater than that of teeth. Keeping the teeth may be a more costeffective and simpler option in the long term in the elderly. 18
CONCLUSIONS Given the issues with oral health care it makes sense to render patients dentally and/or periodontally fit before they enter an aged care facility or hospital. Provision of dental treatment that is easy to maintain in the long term has to be favoured as well as retention of teeth where possible. The elderly are at high risk for further disease and oral care in aged care facilities and hospitals must be improved. This may be by encouraging more dentists to make domiciliary visits, use of dental hygienists, educating patients, carers, nurses and relatives or by lobbying the government to provide better funding. ACKNOWLEDGEMENTS This article is dedicated to Dr Rain Papli, friend and colleague, who was a keen advocate of improving oral health in aged care facilities. DISCLOSURE The author has no conflicts of interest to declare. REFERENCES 1. Roberts-Thomson KF. Oral health status. In: Slade GD, Spencer AJ, Roberts-Thomson KF, eds. Australia’s Dental Generations: The National Survey of Adult Health 2004–2006. Canberra: Australian Institute of Health and Welfare, 2007:81–142. 2. World Health Organization. The WHO Global Oral Health Data Bank. Geneva: WHO, 2007. Available at ‘http:// www.who.int/oral_health’. 3. Darby IB, Phan L, Post M. Periodontal health of dental clients in a community health setting. Aust Dent J 2012;57:486–492. 4. Hopcraft MS, Morgan MV, Satur JG, Wright FAC, Darby IB. Oral hygiene and periodontal disease in Victorian nursing homes. Gerodontology 2012;29:e220–e228. 5. Dye BA. Global periodontal disease epidemiology. Periodontol 2010 2012;58:10–25. 6. Papapanou PN, Wennstrom JL, Grondahl K. A 10-year retrospective study on periodontal disease progression. J Clin Periodontol 1989;16:403–411. 7. Do LG, Slade GD, Roberts-Thomson KF, Sanders AE. Smoking attributable periodontal disease in the Australian adult population. J Clin Periodontol 2008;35:398–404. 8. Brennan DS, Roberts-Thomson KF, Spencer AJ. Oral health of Indigenous adult public patients in Australia. Aust Dent J 2007;52:322–328. 9. Needleman I, McGrath C, Floyd P, Biddle A. Impact of oral health on the life quality of periodontal patients. J Clin Periodontol 2004;31:454–457. 10. Elias AC, Sheihan A. The relationship between satisfaction with mouth and number, position and condition of teeth: studies in Brazilian adults. J Oral Rehabil 1999;26:53–71. 11. Beikler T, Flemmig TF. Oral biofilm-associated diseases: trends and implications for quality of life, systemic health and expenditures. Periodontol 2000 2011;55:87–103. 12. Cullinan MP, Ford PJ, Seymour GJ. Periodontal disease and systemic health: current status. Aust Dent J 2009;54(Suppl 1): S62–S69. © 2015 Australian Dental Association
Periodontal considerations in older individuals 13. International Diabetes Federation. Diabetes Atlas. 4th edn. Brussels: IDF, 2009. 14. Corbet EF, Leung WK. Epidemiology of periodontitis in the Asia and Oceania regions. Periodontol 2000 2011;56:25–64. 15. Meneilly GS, Tessier D. Diabetes in elderly adults. J Gerontol A Biol Sci Med Sci 2001;56:5–13. 16. Australian Research Centre for Population Oral Health. The relationship between diabetes and oral health among Australian adults. Aust Dent J 2008;53:93–96. 17. Genco RJ, Borgnakke WS. Risk factors for periodontal disease. Periodontol 2000 2013;62:59–94. 18. Simpson TC, Needleman I, Wild SH, Moles DR, Mills EJ. Treatment of periodontal disease in people with diabetes. Cochrane Database Syst Rev 2010;5:CD004714. 19. Lalla E, Kunzel C, Burkett S, Cheng B, Lamster IB. Identification of unrecognised diabetes and pre-diabetes in a dental setting. J Dent Res 2011;90:855–860. 20. Lee M, Xia Y, Ng S, Whang A, Moon B, Ngo L, Darby IB. Diabetes risk inpatients with or without periodontitis. Periodontol 2014;32:5–10. 21. Zhang DH, Yuan QN, Zabala PM, Zhang F, Ngo L, Darby IB. Diabetic and cardiovascular risk in patients diagnosed with periodontitis. Aust Dent J 2014 Nov 20 doi: 10.1111/adj.12253 [Epub ahead of print]. 22. Costa FO, Coat LOM, Lages EJP, et al. Progression of periodontitis and tooth loss associated with glycemic control in individuals undergoing periodontal maintenance therapy: a 5-year follow-up study. J Periodontol 2013;84:595–605. 23. Kopelman P. Health risks associated with overweight and obesity. Obes Rev 2007;8(Suppl):13–17. 24. Pischon N, Heng N, Bernimoulin JP, Kleber BM, Willich SN, Pischon T. Obesity, inflammation, and periodontal disease. J Dent Res 2007;86:400–409. 25. Kershaw EE, Flier JS. Adipose tissue as an endocrine organ. J Clin Endocrinol Metab 2004;89:2548–2556. 26. Shimazaki Y, Saito T, Yonemoto K, Kiyahara Y, Iida M, Yamashita Y. Relationship of metabolic syndrome to periodontal disease in Japanese women: the Hisayama Study. J Dent Res 2007;86:271–275. 27. Morita T, Ogawa Y, Takada K, et al. Association between periodontal disease and metabolic syndrome. J Public Health Dent 2009;69:248–253. 28. D’Auito F, Sabbah W, Netuveli G, et al. Association of the metabolic syndrome with severe periodontitis in a large US population-based survey. J Clin Endocrinol Metab 2008; 93:3989–3994. 29. Martinez-Maestre MA, Gonzalez-Cejudo C, Machuca G, Torrejon R, Castelo-Branco C. Periodontitis and osteoporosis: a systematic review. Climateric 2010;13:523–529.
35. Terezakis E, Needleman I, Kumar N, Moles D, Agudo E. The impact of hospitalization on oral health: a systematic review. J Clin Periodontol 2011;38:628–636. 36. Needleman IG, Hirsch NP, Leemans M, et al. Randomized controlled trial of toothbrushing to reduce ventilator-associated pneumonia pathogens and dental plaque in a critical care unit. J Clin Periodontol 2011;38:246–252. 37. Hopcraft MS. Dental demographics and metrics of oral diseases in the ageing Australian population. Aust Dent J 2015;60(1 Suppl):2–13. 38. Slots J. Low-cost periodontal therapy. Periodontol 2000 2012;60:110–137. 39. Gjermo PE, Grytten J. Cost-effectiveness of various treatment modalities for adult chronic periodontitis. Periodontol 2000 2009;51:269–275. 40. Berglundh T, Persson L, Klinge B. A systematic review of the incidence of biological and technical complications in implant dentistry reported in prospective longitudinal studies of at least 5 years. J Clin Periodontol 2002;29(Suppl 3):197–212. 41. Rinke S, Ohl S, Ziebolz D, Lange K, Eickholz P. Prevalence of periimplant disease in partially edentulous patients: a practicebased cross-sectional study. Clin Oral Implants Res 2011;22: 826–833. 42. Roos-Jans aker AM, Lindahl C, Renvert H, Renvert S. Nine- to fourteen-year follow-up of implant treatment. Part II: presence of peri-implant lesions. J Clin Periodontol 2006;33:290–295. 43. Fransson C, Lekholm U, Jemt T, Berglundh T. Prevalence of subjects with progressive bone loss at implants. Clin Oral Implants Res 2005;16:440–446. 44. Heitz-Mayfield LJA. Diagnosis and management of peri-implant diseases. Aust Dent J 2008;53(Supp 1):S43–S48. 45. Cochran D, Schou S, Heitz-Mayfield LJA, Bornstein MM, Salvi GE, Martin WC. Consensus statements and recommended clinical procedures regarding risk factors in implant therapy. Int J Oral Maxillofac Implants 2009;24(Suppl):86–89. 46. Costa FO, Takenaka-Martinez S, Cota LOM, Ferreira SD, Silva GLM, Costa JE. Peri-implant disease in subjects with and without preventive maintenance: a 5-year follow-up. J Clin Periodontol 2012;39:173–181. 47. Heitz-Mayfield LJA, Mombelli A. The therapy of peri-implantitis: a systematic review. Int J Oral Maxillofac Implants 2014;29 (Suppl):325–345. 48. Salvi GE, Zitzmann NU. The effects of anti-infective preventive measures on the occurrence of biologic implant complications and implant loss: a systematic review. Int J Oral Maxillofac Implants 2014;29(Suppl):292–307. 49. Fardal Ø, Grytten J. A comparison of teeth and implants during maintenance therapy in terms of the number of disease-free years and costs – an in vivo internal control study. J Clin Periodontol 2013;40:645–651.
30. Thomson WM. Dry mouth and older people. Aust Dent J 2015;60(1 Suppl):54–63. 31. Darby I. Non-surgical management of periodontal disease. Aust Dent J 2009;54(Suppl 1):S86–S95. 32. Van der Weijden F, Slot DE. Oral hygiene in the prevention of periodontal diseases: the evidence. Periodontol 2000 2011;55:104–123. 33. Deery C, Heanue M, Deacon S, et al. The effectiveness of manual versus powered toothbrushes for dental health: a systematic review. J Dent 2004;32:197–211. 34. Hopcraft MS, Morgan MV, Satur JS, Wright FAC. Dental service provision in Victorian residential aged care facilities. Aust Dent J 2008;53:239–245.
© 2015 Australian Dental Association
Address for correspondence: Professor Ivan Darby Periodontics Melbourne Dental School The University of Melbourne 720 Swanston Street Parkville VIC 3010 Email: [email protected]
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