In older age, the ability to eat with comfort and ease is important not just in maintaining health but as one of life’s basic pleasures. Oral health is also central to communication and self-confidence (even in later life, dental appearance can matter). Periodontal disease, with its consequences of root caries, loss of teeth, discomfort and disruption of mastication, difficulties with speech and avoidance of socialisation can play havoc with fundamental aspects of daily life for the elderly. Evidence is also growing to suggest that periodontal disease may play a significant role in many chronic medical conditions. At the same time, common age-related problems can directly increase the risk of periodontal disease and lead to practical problems that can make
effective oral health management challenging. For example, poor manual dexterity (as a result of osteoarthritis, Parkinson’s disease or stroke) may limit oral care, while reduced mobility makes repeated travel to the dental surgery for treatment difficult.
Periodontal disease is common in later life and the incidence is rising fast as the aged population grows. According to the UK Department of Health’s Action Plan Choosing Better Oral Health in 2007, 54 per cent of adults aged over 16 had moderate signs of periodontal disease while more severe disease was found in five per cent, most of whom were aged over 65. As more than half the population in the UK can now expect to live to past 80 and a rapidly rising number are reaching their 10th decade, the impact of periodontal disease within society increases.
Poor oral health can result in lower nutritional status, especially in the elderly where it compounds other factors such as reduced appetite and drive to eat, and cognitive or mobility difficulties that limit meal preparation. For example one study of people aged 79+ found that the mean daily nutrient intakes were significantly lower in those with fewer natural or functional teeth, or ill-fitting dentures, and that natural teeth or well-fitting dentures were associated with more varied nutrient intakes and greater dietary quality. Periodontal disease can therefore leave the elderly at increased risk of nutritional deficiencies and all their sequelae, from poor immune function and increased risk of infection to bone and muscle weakness, slower wound healing and other compromises in tissue function. In a vicious circle, the nutritional deficiencies may exacerbate the periodontal disease. As a practising geriatrician working with people recovering from major illness, rehabilitation is often hampered by clinical problems aggravated by deficiencies of iron, vitamin D, folate and other nutrients. A considerable number of my patients have poorly managed periodontal disease and many tell me they haven’t seen a dentist in years.
Recent understanding now points to periodontal disease as an independent risk factor for systemic conditions such as diabetes, lung disease, heart disease and stroke.Several mechanisms have been proposed, including spread of infection from the oral cavity as a result of transient bacteremia, injury from the effects of circulating oral microbial toxins, and metastatic inflammation induced by oral microorganisms.
Twenty years ago research linked myocardial infarction to poorer oral health and suggested that periodontal disease may be a risk factor for the development of coronary heart disease. In 2007 a meta-analysis of more than 50 further studies concluded that “both the prevalence and incidence of coronary heart disease are significantly increased in patients with periodontal disease”. Central to the pathophysiology is inflammation triggered by dental plaque, which leads to disruption of cholesterol plaques within the coronary arteries, resulting in thrombus formation and occlusion. In the Scottish Health Survey brushing teeth less than once daily was linked to increased systemic inflammatory markers such as C-reactive protein (CRP) and carried the same level of risk of cardiovascular events as hypertension. C-reactive protein levels have been shown to drop following a course of periodontal therapy, and although it was not clear whether this was cardioprotective, positive outcomes have been obtained from studies that have investigated the effects of periodontal interventions on endothelial function.
Periodontal disease has also been linked to diabetes. Uncontrolled type 2 diabetes is a risk factor for severe periodontitis, while periodontal disease is associated with poor glycaemic control, which improves when the periodontal problems are effectively managed.
Respiratory disease, especially pneumonia, is common in older adults. Genetic mapping has shown that pathogens recovered from bronchoalveolar fluid of hospitalised elderly people are the same as those found on their dental plaque. This highlights how periodontal disease is an important reservoir for respiratory infection, and how oral hygiene interventions may reduce the risk of developing pneumonia.
Interactions between periodontal disease, osteoporosis, arthritis and Alzheimer’s disease are also being explored. In osteoporosis, for example, periodontal disease is associated with accelerated alveolar bone loss. Alternatively, a systemic reduction in bone remodelling may modify the response of the periodontal tissues to bacterial plaque. Meanwhile some studies indicate that oestrogen replacement therapy may reduce gingival inflammation and the risk of tooth loss.
So what are the messages for those caring for the elderly? Preventative measures aiming to preserve good function and reduce interaction with other conditions are key, including good oral hygiene and the active management of periodontal problems. Elderly care physicians need to understand the links with chronic conditions, and provide individualised oral hygiene instructions with appropriate aids and clear communication to caregivers to maximise oral health.