oral implications and prevention strategies for older

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Oral Implications and Prevention Strategies for

Older Adults

Dr. Lisa Knowles

Introduction

• This presentation today is being sponsored by Colgate-Palmolive Company (Colgate).

• I am making this presentation on behalf of Colgate.

• The information being presented today is consistent with FDA rules and guidelines.

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Introduction

• This presentation looks at oral health impacts for older adults, including certain oral and dental diseases commonly seen in this population.

• Later on, we will review recommended preventive strategies for oral care management in older adults

• I will identify several Colgate products that are effective options for these preventive strategies, and we will discuss the products’ intended uses.

• Please note that none of the Colgate products that will be discussed today are indicated to prevent or treat serious gum disease (periodontitis) or other diseases, such as Diabetes Mellitus, not identified in the labeling.

Contents

Epidemiology and Prevalence

Physiologic Changes in the Aging Dentition

Oral and Dental Diseases in Older Adults

Relationship Between Periodontal Disease and other Systemic Conditions

What is an Older Adult’s Dental Future?

Prevention and Healthy Living

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2050

21%

Older Adult PopulationGlobal Data‐ Percentage of the population aged 60 years or older

2013

11.7%

http://www.un.org/en/development/desa/population/publications/pdf/ageing/WorldPopulationAgeing2013.pdf

Global birth rate in 1950 was 5 children/womanIn 2017 is was 2.5 children/womanIn 2050 projected to be 2.2 children/woman and life expectancy in 2050 will be rising to 74 from current 68.

Older Adult Population in the U.S.

• Older adults make up one of the fastest growing segments of the American population

• The current accepted age to define an older adult is 65 years*

• There are 65 million people age 60 and older in the U.S.**

• The older population will increase dramatically from 2014-2030 due to the Baby Boomer era. From 2000 to 2030, older people will grow from 35 million to 74 million and represent 21% of the population. *

*WHO‐Health statistics and health information systems: http://www.who.int/healthinfo/survey/ageingdefnolder/en/**Profile of Older Americans:2016. Retrieved from http://www.aoa.gov/Aging_Statistics/ https://www.acl.gov/node/579

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https://agingstats.gov/docs/LatestReport/Older‐Americans‐2016‐Key‐Indicators‐of‐WellBeing.pdf

Changing Trends - Older Adult Population in U.S.

How Are We Getting So Old?• Life expectancy at birth is increasing with time

• Better living conditions across the life span

• Improved geriatric care

• Greater education attainment• Better knowledge on health

• Greater use of prevention services

• Healthier lifestyles

• Greater use of other services to support health

• Increase in use of prescription medications(poly-pharmacy)

Adapted from ADEA Curriculum Resource Center: Older Americans 2012, Key indications of well‐being Washington DC: Federal Interagency forum on Aging‐Related Statistics,2012.

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Changing Trends - Older Adult Population in U.S.

• Decline in edentulism in older adults 2000-2010

• More retained teeth with higher prevalence of root caries and untreated dental decay

• Greater awareness, better oral health leads to higher expectations for healthcare• Increasing the need for change in

traditional dental practice

Adapted from ADEA Curriculum Resource Center: Health, United States, 2011 Washington DC: U.S. department of health and human services, Center for Disease Control and prevention, National Center for Health Statistics 2012,

Prevalence:Dental Statistics of the U.S. Aging Population

• 92% have had decay• 27.27% of seniors over 65 have no teeth (edentulous)• 23% have untreated caries• 90% have income less than or equal to 200% of the

poverty level• Black seniors, current smokers, & those with lower

incomes and less education have fewer remaining teeth

The increase in restorative work needed by patients between now and 2030 will be in those over the age of 50 years

National Institute of Dental and Craniofacial Research, 2009

https://www.nidcr.nih.gov/research/data‐statistics/tooth‐loss/seniors

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Older Adult Population in U.S.

• Close to 70 percent of older Americans do not have dental insurance1

1. R.J. Manski & E. Brown. (2007). MEPS Chartbook No. 17: Dental Use, Expenses, Private Dental Coverage, and Changes, 1996 and 2004. Retrieved from http://meps.ahrq.gov/data_files/publications/cb17/cb17.pdf

Dental Health Problems Related to Aging

The population is growing older while retaining their teeth

The retained teeth have more extensive (and older) restorations in them

The repair/reconstruction of these older teeth is highly challenging

There is more dentin exposed on the retained teeth and therefore less potential to remineralize

Prescription medications can cause xerostomia, leading to high risk of oral disease

Older adults may be less able to maintain good oral hygiene

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Resistance to Getting Older

• https://www.youtube.com/watch?v=2TBc_YB600c

• How Do We Handle This In Dentistry?

Societal Concerns

• Fear of Getting Older

a. Dying

b. Disabled/Capabilities

c. Fear of Losing Independence

• Pride & Admitting Shortcomings (So they may lie to us)

a. Not cleaning teeth as well

b. Unable to hold floss

c. Eyesight not as good to see problems

d. Feeling pain

Never Shame them. Teach them. Help them cope.

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Geriatric Dentistry

Is the delivery of dental care to older adults involving the diagnosis, prevention, and treatment of problems associated with normal aging and age-related diseases as part of an interdisciplinary team with other health care professionals

http://www.bionity.com/en/encyclopedia/Geriatric_dentistry.html

What Should We Do Differently In Our Offices for Older Adults? Exam Differences

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Evaluation of an Older Adult at Dental Visit/Office

Older Adult

Patient

- Patient identification

- Chief complaint-allow time

- Dental history/help with tech

- Past medical history

- Review of symptoms

- Medications

- Allergies

Previous Illnesses

- Diet history

- Social history

- Habits

- Physical oral examination and head and neck exam

- Vital signs

- Lab assessment

Tennstedt SL, Brambilla DL,Jette AM, McGuire SM. Understandingdental service use by olderadults: sociobehavioral factors vs need. J Public Health Dent 1994; 54:211–9.

Dental Status

Medical StatusCurrent Observed Health

Personal Health & Info

Multiple Issues, Diagnoses, Needs

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Contents


Basic Screening & Exam Differences

Physiologic Changes in Aging Dentition





Dental Conditions Affecting Older Adults

Key Considerations- Patterns of oral conditions differ across lifetime

• Coronal caries- most common in adults

• Root caries – most common in over 65-year olds

• Risk of periodontitis increases directly with age

• Risk of oral cancer increases dramatically with age

- Important to be able to differentiate:• Changes due to years of normal use (such as tooth wear)

• Changes associated with disease

Adapted from ADEA Curriculum Resource Center

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Extensive tooth wear

Significant loss of vertical

dimension

Fractured and brittle teeth

Darkened color

Failed and failing restorations

History of caries

Limited attachment loss, which is part of normal aging

Limited tissue inflammation

Common Changes in Aging Dentition

Source: Clinical approach to the elderly patient, Geriatric medicine, 2nd ed, 1988 ( 23‐36).


• Tooth wear• Cumulative effects of

abrasion, attrition and erosion over the years

(undiagnosed GERD,

apnea?)

• Exposed dentin• More yellowish teeth

• Dentin hypersensitivity

Adapted from ADEA Curriculum Resource Center: Health, United States, 2011 Washington DC: U.S. department of health and human services, Center for Disease Control and prevention, National Center for Health Statistics 2012, Table 129

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• Brittle teeth • Chipping

• Development of fissures and fractures

• Secondary dentin (blue arrows)• Smaller pulp chambers dentin is laid down

resulting in greater width of dentin

Courtesy of: Charles Solomon, DDS, Columbia University College of Dental Medicine

Thomson WM Epidemiology of oral health conditions in older people. Gerodontology 2013; 30: 26–31.

Normal Aging - Periodontium and Oral Mucosa

Gingival recessionDiminished

inflammatory and immune responses

Thinning of oral mucosa

Impaired wound healing


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Normal Aging - Salivary Glands

Salivary gland function

• Normal function unless impacted by:• Atrophy of salivary gland tissue

• Medications

• Specific systemic disorders (Diabetes Mellitus, SjÖgrens syndrome)

More than 400 medications reported to have dry mouth as a side effect, including:

• Antidepressants Antihypertensives

• Antihistamines AntiasthmaticsThomson WM Epidemiology of oral health conditions in older people. Gerodontology 2013; 30: 26–31.

Normal Aging - Masticatory System

• Masticatory function may be reduced even if teeth are retained

• The masticatory system could be impacted by reduction in masticatory muscle mass with age

• Preparation of food bolus for swallowing may be reduced

• Taste may be reduced resulting in loss of appetite


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Contents


Physiologic Changes in Aging Dentition





.


• Dental caries – (root and/or recurrent)

• Periodontal disease

• Edentulism/ missing teeth

• Oral cancer

• Dry mouthCourtesy of Ann Spolarich RDH, PhD

Berkey D, Berg R. Geriatric al health issues in the United States. Int Dent J 2001; 51: 254–64.


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Dental Caries in Older Adults

• Prevalence of root caries and recurrent caries is higher

• Caries risk factors• Reduced salivary flow (dry mouth)

• Reduced frequency and effectiveness of oral self-care (mechanical plaque removal)

• Heavy plaque deposits as result of poor cleaning

• Presence of removable partial dentures

• Increased consumption of sugars and simple carbohydrates

• Recent Illnesses

Courtesy of Agnes Walls BDS, Edinburgh Dental Institute

Berkey D, Berg R. Geriatric al health issues in the United States. Int Dent J 2001; 51: 254–64.

Think Candy Jars

Burcham Hills and other places

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Think Colgate® Fluoride Therapies

RX Treatment at Home

PreviDent® 5000 Liquid Gel Toothpaste (Rx Only)

PreviDent 5000 Plus® (Rx Only)

PreviDent® 5000 Gel (Rx Only)PreviDent® Rinse

GelKam® Gel

OTC at Home

Phos‐Flur® Rinse

Fluoride Toothpaste

Fluoride Sources

• Prescription strength supplemental fluoride for home use• 1.1% neutral gel or dentifrice: 5000ppm• 0.2% neutral sodium rinse: 920ppm• 0.4% stannous fluoride gel: 1000ppm

• In-office treatments• Gels• Rinse (Hydris)• Foam

• Fluoride products intended for xerostomia patients• 1.1% neutral sodium fluoride (5000ppm) with glycerin,

phosphate, SLS free

Adapted from ADEA Curriculum resource Centre: ADA council on scientific affairs; J Am Dent Assoc 2006; 137 (8) 1151‐9.

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Periodontal Disease in Older Adults

• Prevalence of periodontal disease increases over time. X-rays needed

• Loss of attachment continues, perio charting needed.

• Attachment loss appears/begins in new sites

• Key risk factors for periodontal disease− Smoking− Systemic conditions such as

Diabetes Mellitus− Physical impairment− Presence of specific periodontal

pathogens

Locker D, Slade GD, Murray H.Epidemiology of periodontal disease among older adults: a review. Periodontol2000 1998; 16: 16–33.Holm‐Pedersen P, Agerbæk N, Theilade E. Experimental gingivitisin young and elderly individuals. J Clin Periodontol 1975; 2: 14–24.

Oral Cancer in Older Adults

• Oral Cancer statistics in U.S.− Median age at diagnosis: 62 years

− Traditional risk factors

• Smoking

• Alcohol consumption

− Emerging risk factors (younger ages)

• Human papillomavirus (HPV16, HPV 18)

− For oral squamous cell carcinoma, the stage at diagnosis and survival rates are worse for African Americans than Whites

− 40,000 new cases reported each year in U.S. resulting in 7,000 deaths

U.S. Department of Health and Human Resources, national institutes of health, National cancer Institute, 2012

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Oral Cancer in Older Adults

Carcinoma in situ65 year old female who smoked one pack of cigarettes per day for 45 years

Squamous Cell Carcinoma67 year old male history of heavy cigarette smoking

Courtesy of David J. Zegarreli DDs, Colombia University College of Dental MedicineAdapted from ADEA Curriculum Resource Center. www.adea.org/crc

Oral Mucosal Lesions in Older Adults

• Candidiasis – occurs in patients with Diabetes Mellitus, and is linked to long term use of corticosteroids and/or antibiotics

Acute atrophic candidiasis Chronic atrophic candidiasis

Courtesy of David J. Zegarreli DDs, Colombia University College of Dental MedicineAdapted from ADEA Curriculum Resource Center. www.adea.org/crc

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Oral Mucosal Lesions in Older Adults

Pemphigus Vulgaris Pemphigoid

Courtesy of David J. Zegarreli DDs, Colombia University College of Dental MedicineAdapted from ADEA Curriculum Resource Center. www.adea.org/crcTehranchi‐Nia Z1, Qureshi TA, Ahmed AR. Pemphigus vulgaris in older adults. J Am Geriatr Soc. 1998 Jan;46(1):92‐4.

Autoimmune disorders –Common disorders are Pemphigus and mucous membrane Pemphigoid

• Dry mouth is a symptom, not a disease

• Xerostomia and salivary gland hypofunction are not necessarily concurrent.

Xerostomia

Salivary Gland

Hypofunction

Dry Mouth / Xerostomia in Older Adults

*DM

* Dry Mouth

Orellana MF, Lagavere MO, Boychuk DGJ, Major PW, Flores‐Mir C. Prevalence of xerostomia in population‐ based samples: a systematic review. J Public Health Dent 2006; 66:152–8.

Salivary glandhypofunction is not a normal sign of aging.

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Approximately 20% of adults are affected

- 44 million in the US

>10% of adults suffer from xerostomia

Epidemiology of Xerostomia

Sreebny & Vissink (eds.) in: Dry Mouth. The malevolent symptom: A Clincal Guide. 2010. Wiley‐Blackwell.

10%


• Salivary flow rate for a dry mouth• Resting salivary flow rate of

<0.1ml/min

• Stimulated salivary flow rate of

1.0 ml/min

• Associated conditions• Diabetes Mellitus

• SjÖgren’s syndrome

• Side effect of medications

• Habitual mouth breathing

• Head and neck radiation therapy

*Adapted from ADEA Curriculum Resource Center‐presentation on Older Adults

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Indicators• Feeling of dryness of oral

mucosal surfaces • Sensitive mucosa• Dry lips • Bad breath

Causes difficulty in:• Mastication

• Swallowing

• Speaking

• Solubilizing food components

*Adapted from ADEA Curriculum Resource Center‐ presentation on Older Adults


www.nice‐smiles.comCaries Candidiasis/ tooth loss

Caries

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Hydris—New Products (paste and rinse)

How Does It Work?

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Contents







Periodontitis in Relation to Systemic Conditions

• Diabetes Mellitus

• Cardiovascular Disease

• Respiratory Disease (influenza)

• Other possible relations• Arthritis

• Dementia/Alzheimer’s Disease

• Obesity

• Cancer

• Low Birth Rates

• Premature Births

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Diabetes and Periodontitis

• Poorly controlled diabetes increases the risk of periodontitis

• Periodontitis can make glycemic control more difficult.

Grossi SG, Genco RJ. Periodontal disease and diabetes mellitus: a two‐way relationship. Ann Periodontol. 1998 Jul;3(1):51‐61.

Due to the complex pathophysiology of periodontitis and its impact on the risk for

CVD-- the bacteria, risk factors, and inflammation all need to be addressed when

developing a treatment plan.

Patients with moderate to severe periodontitis should be informed that they might be at an

increased risk of atherosclerotic CVD.

Periodontitis and Chronic Disease –Cardio Vascular Disease (CVD)

Reyes et al. Periodontal Bacterial invasionand infection:contribution to atherosclerotic pathology. J Clin Perio proceeding s of workshop with EFP/AAP 2012

Schenkein et al. Inflammatory mechanisms linking periodontal diseased to cardiovascular diseases. J Clin Perio proceeding s of workshop with EFP/AAP 2012

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Contents







Impact of Life Long Habits on Dental Future?• Factors that increase risk:

− Alcohol use− Smoking/ tobacco use− Recreational use of drugs− Unprotected sexual activity− Cognitive impairment− Limited health education on health

consequences− Failure of health care professionals to assess

risk behaviors

• Increased systemic health risks− Oropharyngeal and other cancer− Oral / systemic infections− Infectious diseases− Substance abuse/ addiction

Adapted from ADEA curriculum Han B et al, Addiction 2009;104(1): 88‐96.

Istockphoto.com/igor Skribic

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Their Care Is Often Affected By the Care Givers. Ability To Get Care & How To Guide the Care Givers

• https://www.youtube.com/watch?v=DlVRIfrz8l4

Contents







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Prevention and Healthy Living/Improving Quality of Life For Older Patients

• Benefits reaped regardless of age

• Approaches vary across the lifespan

• Oral health contributes to overall wellness

Preventive interventions Healthy lifestyle

Strout KA, Howard EP. The six dimensions of wellness and cognition in aging adults. Review. J Holist Nurs. 2012 Sep;30(3):195‐204. Epub 2012 Jun 19 .

Prevention Strategies in Dental Office

Careful medical history screening at every visit

Record vital signs at each visit

Update medications list & consider oral/systemic concerns

Ensure adequate oxygen supply

Establish emergency management protocol

Train staff on life support training such as providing CPR

Think Beyond Their Teeth‐sleep apnea, erosion, mental

Allow adequate time in schedule

Michael I. MacEntee and Kavita R. Mathu‐Muju. Confronting dental uncertainty in old age. Gerodontology Special Issue: Developing Pathways foOral Care in Elders Volume 31, Issue Supplement s1, pages 37–43, February 2014.

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The Older Adult Population: Defined by Level of Dependency And Lifestyle

Healthy – No Dependency

Pre‐Dependency

Dependent Severely /high Dependence

Population Large Moderate Small Very Small

Specific Oral Care Needs

Cosmetic +++Preventive +Therapeutic +Palliative Care+

Cosmetic +Preventive ++Therapeutic ++Palliative Care++

Cosmetic Preventive ++Therapeutic ++Palliative Care++

Cosmetic Preventive +++Therapeutic +++Palliative Care+++

Specific Problems Maintain Health Cosmetics

Poly‐pharmacyHigh Risk dentitions

+ Difficulty withoral hygiene care

+ Difficultprofessional interventions

Preventive Solution

Anti‐bacterial TPAnti microbial MW

Anti‐bacterial TPHigh fluoride ToothpasteAnti microbial MWDenture cleaner

High fluoride TP for dry mouthAnti cavity fluoride rinse

Oral pain relieverHigh fluoride TPAnti cavity fluoride rinseChlorhexidineoral rinse

Iain A. Pretty, Roger P. Ellwood, Edward C.M. Lo, Michael I. MacEntee, Frauke Muller, Eric Rooney, William Murray Thomson, Gert‐Jan Van der Putten, Elisa M. Ghezzi, Angus Walls and Mark S. Wolff. The Seattle Care Pathway for securing oral health in older patients Elders Volume 31, Issue Supplement 1, February 2014.

Help Them Prevent Cavities:Recent Insights into Caries Prevention

• Secondary caries is related to numbers of both S. mutans and Lactobacillus spp.

• For individuals with initially high numbers of oral S. mutans , the control of secondary caries was more difficult with a conventional preventive program

• The use of 5,000 ppm (Rx only) fluoride toothpaste and improvement in diet may help support the preventive program

Adapted from ADEA Curriculum Resource Center: presentation on Older adults Chapter 3

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Help Them With Products: Deep and Gentle CleanIndividualized Tooth Brush Selection; Spend time with Older Patient and Personalize Their Toothbrush & Floss Preferences

Features to look for• Should effectively remove plaque at the gum line

and between teeth• Soft, Slim Tip tapered dense bristles• Handle with an easy non-slip grip• The brush head size should suit the patients’

needs• Consider Electric Toothbrush

Eg. Colgate® Slim Soft™ Toothbrush

Oral Irrigation – Air/Water Flossers –Electric-TB’s

• Daily oral irrigation with water helps reduce plaque and gingivitis

• Specially helpful in patients with special needs

• Removed both loose and adherent plaque biofilm

• May produce local host modulation (pro and anti-inflammatory mediators)

Adapted from ADEA Curriculum Resource Center: Jahn CA. The dental water jet: a historical review of the literature. J Dent Hyg 2010;84(3);114‐20.Al‐Mubarak S et al; A comparative evaluation of adjunctive oral irrigation in diabetes. J Clin Perio 2002;29 (4); 295‐300.

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Antiseptic / Antimicrobial Therapies

• Reduces bacterial load in the mouth

• Indications • Prevent and reduce supragingival plaque formation and

gingivitis

• Adjuncts to managing xerostomia-related bacterial complications

• Products: OTC and Prescription-strength• OTC - Antiseptic rinses and anti microbial dentifrices –

treatment of gingivitis which is reversible

• Prescription- strength locally delivered antibiotics –professionally applied in-office for treatment of periodontal pockets

Lang NP et al. J Perio Res (1982).

Provide Helpful Resources To Our Patients & Continue to Learn as Providers

http://oralhealthamerica.org/programs/wisdom‐tooth‐project/

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Overall Summary

• Oral health is a vital component of overall wellness and quality of life

• Level of optimal wellness varies across individual lifetime

• Attaining optimal oral wellness is an essential health goal for older adults

• Older adults engage in lifelong habits that increase their risk for oral and systemic disease

• Caries and periodontal disease are still the most common oral disease seen in older adults

• Begin early with lifelong healthy habits. Age one dental visits. Stephen Covey says, “Begin with the end in mind.”

Dr. Lisa KnowlesIntentionalDental [email protected] New Tip

oral implications and prevention strategies for older

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