Oral Health As We Age

A 75-year-old patient of mine asked me to make recommendations, which would help her chew adequately when she entered a nursing home. She was in relatively good health and wasn’t planning on entering a facility soon. Her concern was that several of her relatives had bad experiences which she hoped to avoid. I had never been asked this question in 30 years as a dentist but had often seen patients’ oral health deteriorate as they aged, including when they entered long-term care facilities. So after research and much contemplation, I have developed some observations and recommendations.

As we age, there are certain inevitabilities. Our manual dexterity decreases, which make it harder to keep our teeth, gums, and dental appliances clean. Our teeth and dental replacements wear and become less efficient in chewing. We take more medications, making our mouth dryer. This leads to greater friction on our oral tissues, resulting in ulcers and sore spots. A dryer mouth also makes the cavity-causing bacterial acids stronger, resulting in higher cavity rates. Receding gums expose more cavity prone root surfaces. The ability to fight oral infection decreases with some of the diseases that plague us, such as diabetes. The increased bacterial and fungal levels in our teeth, soft tissues, and dentures, all can increase the chance of contracting pneumonia. These bacteria also enter the bloodstream, complicating existing conditions such as heart disease and diabetes.

Five percent of Americans are in nursing homes currently. By the time we enter a long-term care facility, many of the above issues have worsened and we have to rely on others for our oral hygiene. If a patient cannot feed themselves, they probably cannot provide their own oral care. Nursing assistants usually provide this help. Many are not trained and bathing and eating assistance take precedence over oral hygiene. It may sound hopeless, but there are many steps we can take to ensure our future health and quality of life. The preventive measures we take throughout our lives have the strongest influence on our oral health. Regular dental visits, routine flossing, and using an electric toothbrush and antibacterial mouth rinses are most important. We recommend having dental care needs met at a young age, so when necessary procedures come along later in life they may be more easily tolerated. Dental implants are a wise investment as single tooth replacements because they cannot get cavities, but can be modified to hold in dentures if other teeth are lost. Nursing home patients with implant held dentures can eat more nutritious foods because they can chew harder than patients with conventional dentures. They are less likely to lose their dentures because they’re not removed as much. Selecting the right long-term-care facility and continuously monitoring the care that we or our loved ones receive is crucial to good health, comfort, and quality of life.

Oral Health Facts In Nursing Homes

Five percent of all Americans or 1.75 million people are in long-term health care facilities or nursing homes. Ninety-one percent of nursing home residents are 65 or older and 46 percent are 85 or older. A recent study showed 79.6 percent of the residents had teeth, and all had calcified plaque (tartar) on their tooth surfaces. One-third of the residents had calculus (tartar) that covered two-thirds or more of the tooth’s surface. Another study found the greatest single need was for routine oral hygiene (72 percent), and adjustment of loose dentures was (46.4 percent).

Periodontal (gum) problems were 43 percent and 36 percent were root cavities. The conclusion was that a high proportion of elderly nursing home residents suffer from lack of oral hygiene and neglect oral health. High levels of oral bacteria affect the rest of the body. It is associated with coronary artery disease, diabetes, and pneumonia. Serious periodontal disease may have the potential to affect blood glucose control and contribute to the progression of diabetes. Bacteria presented on the teeth, oral soft tissue, and dentures enter the throat and lungs to cause pneumonia. Four million cases of nursing home acquired pneumonia (NHAP) occur a year and it is the most common infection in chronic care facilities. It is the leading cause of hospitalizations and death. One study found patients with poor oral care were three times more likely to contract pneumonia than patients with good oral hygiene and twice as likely to die from the pneumonia.

The primary cause for this oral health crisis is that oral hygiene is not considered a priority. Nursing assistants receive very little training in oral hygiene, and therefore assistance in bathing and eating is of higher priority than oral care. One study found that only 16 percent of residents received oral care. When patients brushed their own teeth they were stopped by the nursing assistant before 2 minutes. A toothbrush was available only 27 percent of the time. Mouthwash was only present 18 percent of the time. When the patient was supervised cleaning their own teeth, no encouragement, praise, or smiles were given in recognition of their oral care.

Many nursing home residents are resistant to the attempts of nursing assistants to provide oral care. One study found 63 percent of patients were resistant to oral hygiene attempts. Another study where 90 percent of patients were diagnosed with dementia; all needed significant help with dressing and bathing, and 94 percent required assistance with personal hygiene, including mouth care. Only 28 percent received any type of mouth care; of that number, the average time for received mouth care was 1 minute and 12 seconds. In a study of 187 nursing home residents, researchers noted associations between persons with highly compromised dentition (no teeth, teeth with 1 full-denture plate, or 6 or fewer teeth) and weight loss.

In another study that examined relationships between oral health status and weight in persons newly admitted to a nursing home, researchers found an association between low body mass and poor oral health. Nearly one-third of all older adults experience xerostomia or dry mouth. The average nursing home resident takes eight medications daily: anticholinergics, antihypertensives, antidepressants, diuretics, anxiolytics, and antihistamines. All of which diminish salivary production and alter the ability of the oral environment to fight the effects of harmful microbes.

Professional dental care is limited for nursing home residents. Seventy percent of persons age 65 years and older lacked any dental insurance, as compared to 34 percent of persons age 45-64. When dental coverage for older adults was examined according to age strata, 64.6 percent of older adults age 65-74 lacked dental insurance and 75.7 percent of adults age 75 and older lacked dental insurance. Medicare does not cover routine dental care; Medicaid coverage varies between states, but either does not cover dental care or compensates dentists so poorly that no one will accept it.

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