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Senior Dentistry

Senior Dentistry

In the year 1900, approximately three million Americans (approximately 3% of the population) were 65 years of age or older. Fewer than 200,000 were 85 or older. Now that number is times twelve. As of the last census in 2014, there are about 46.2 million people over the age of 65 in the U.S., of whom over five and a half million are over the age of 85. There are now more people in this country over the age of 65 than there are children under the age of 8, and the proportion of those over the age of 85 is growing at a faster rate than that of any other age group. The number of seniors is projected to reach 92 million by 2060, with 18.2 million age 85 or older. This will comprise 20.9% of the population.

Senior citizens are seeking dental care at unprecedented rates and in numbers that outweigh their proportion of the population. Today, Increasing numbers of older adults are keeping their natural teeth unlike past generations in the 19th and 20th centuries. Unfortunately, oral health care is still marginalized in our country and seniors keeping their teeth are at risk. According to a National Health and Nutrition Examination Survey (NHANES) done between 1999-2004, approximately 18% of adults aged 65 years or older with retained natural teeth have untreated cavities, while a 2009-2012 NHANES found that 68% of these patients have periodontal gum disease.

Often misconceptions and false stereotypes, regarding seniors, can inadvertently and incorrectly influence assessment, diagnosis, and treatment approaches for seniors.

The Four Common Dental Issues for Seniors

1. Periodontal Disease
2. Root Cavities
3. Poor Fitting Dentures
4. Oral Systemic Health considerations

Periodontal Disease:

Periodontal Disease is an infectious, transmittable disease of the supporting tissues (gum and bone) in the mouth, caused by very specific strains of bacteria. It is a preventable disease. However, once you have the disease it is not curable but rather controllable. The level of control is relative to the severity of the disease. The more the severe the disease, the less able you are to control the disease on your own. The foundation of the teeth (bones and gum tissue) are compromised by the infection and associated inflammation and once the foundation of the teeth erodes away tooth loss is inevitable. There are some prevailing myths about periodontal or gum disease that are important to note:

Myth #1: Gum Disease Is Inevitable with Aging

Gum disease does not have to be a part of aging. It is an infectious disease caused by bacteria that is preventable but once you have it, it is not curable. If you avoid the infection you avoid the disease and the loss of your teeth to it. Unfortunately, it is easily transmitted by kissing, sharing utensils, or drinking glasses or food at any point over one’s lifetime. Did you ever drop a pacifier on the ground and put it in your mouth to clean it before giving back to you baby? You just transmitted all the bacteria from your mouth to your baby’s mouth. Those who smoke, have dry mouth or take certain medications increase the likelihood of developing periodontal disease.

Myth #2: Periodontal Disease is not a concern because I do not feel any pain or discomfort

Periodontal disease is often described as a silent disease. Most often the patient can have advanced gum disease and be completely unaware of the chronic infection. Symptoms, which include, bleeding gums, loose teeth, tooth movement, and cold sensitivity are seldom observed until the disease is in a very advanced or severe state. Unfortunately, gum disease is not that easy to recognize without inspection from a dentist. Many seniors allow this problem to develop over the course of many years because they have not noticed any symptoms along the way. This further expresses the importance of regular dental visits so that a diagnosis can be made before it becomes too serious. If you wait until you observe these symptoms to treat the disease, odds are very good that you will lose some teeth.

Myth #3: Bleeding From Brushing & Flossing Isn’t A Problem

Wrong again. Bleeding from the gums following brushing and flossing is one of the hallmark signs that you have active periodontal disease. Just remember your gum tissue is bacteria’s freeway into your blood stream. Additional symptoms of gum disease include:
Mouth Sores
Changes in the way your teeth fit together
Swollen or tender gums
Changes in the fitting of dentures
Persistent bad breath or bad taste
Loose or separating teeth
Pus between the teeth and gums
Receding gums

Myth #4: Gum Disease Won’t Affect My Overall Health

As mentioned above, periodontal disease has been associated with many conditions, such as heart disease. Studies also link causality to diabetes and heart disease. Which means that your gum disease could cause you to become diabetic and could cause you to have Acute Coronary Syndrome. These specific bad bacteria can alter your bodies DNA to ensure their survival and growth. There is also a link between gum disease and specific strains of bacteria that cause it called Spirochetes and Alzheimer’s disease. Other conditions include the increased difficulty to manage blood sugar levels for diabetics, osteoporosis, respiratory disease, pregnancy complications, and even cancer.

Root Caries

What is root caries? Tooth decay (caries, cavities) is not just a problem for the young, but can happen at any age. Certain types of cavities are more common as we age. Root cavities occur where the gum tissue and bone have receded (shrunk) down the tooth to expose the root. The structure of the root (cementum/dentin) is seven times softer than the enamel we have on the top portion of the tooth. This makes it more prone to damage from acid attacks in the diet or by bacteria. Often, it is a side effect of periodontal disease (see above). One disease leads to another.

What is the cause of root caries?

The cause of all cavities is bacteria. Bacteria adhere to one another to form a sticky white mass called plaque or biofilm. This plaque tends to adhere to all available surfaces of a tooth leading to tooth decay, if not removed from the tooth surface. The plaque secretes acid by products that dissolve the tooth structure and make it soft. The root of the tooth must be exposed for root decay to occur. Due to the softness of the tooth structure it decays rapidly if plaque remains on it for a short period of time. Changes in the level of saliva in your mouth can also put you at higher risk for developing caries. Saliva is a natural defense barrier that keeps your teeth and mouth healthy. Saliva is made by glands located in various locations in the mouth. Certain types of medications, radiation or chemotherapy treatments and other diseases can cause these glands not to work properly reducing saliva flow. This reduction in saliva flow increases the bacteria’s ability to attach and adhere to teeth and thus increases cavities and tooth decay.

How do I know if I have root caries?

Root Decay can be present with no awareness of it. The warning signs that often accompany tooth decay, such as sensitivity to sweets or cold, may be absent. Another factor that contributes to any lack of sensation is that as we age the nerve inside the tooth recedes and the tooth becomes more insulated to sensation and pain. Typically, root caries is first discovered by a dentist or dental hygienist during a routine wellness cleaning or exam when they can feel the softened root with a dental instrument. Like an Iceberg, often what is under the surface is more extensive than what is above the surface. Radiographs (x-rays) can be helpful in finding root caries between the teeth or in hard to see areas but sometimes root cavities can be difficult to see on a film depending on where on the tooth the decay is occurring.

What options are there to repair the damage to the tooth?

The proximity of the decay on the tooth in relation to the nerve and the gum tissue make root caries difficult to treat. The damage to the foundation of the tooth also increases the risk of the tooth breaking off at the gum line. In some instances, the tooth is not repairable and may need to be removed. In other situations, the tooth can be restored but may require a root canal (to remove the infected nerve tissue or sensitivity), a core buildup, and a crown. This can be a costly repair. This is truly where an ounce of prevention can help avoid a pound of cure. At times, so much damage has been done the tooth must be removed. This is why it is so critical to have frequent exams so that root caries can be found at an early stage.

How can root caries be avoided?

Although it may be more difficult if your gums have receded, the most important thing you can do is thoroughly clean your teeth several times, every single day. This keeps the plaque and bacteria levels to a minimum. When we eliminate the cause of the disease we break the cycle. We have many tools and techniques to help you tailor treatment to your individual needs. Water flossers, proxy brushes, interproximal picks or brushes, Sulca brushes, end tufted brushes and other oral aids are often very helpful. Be sure to tell your dental team if you have physical limitations that make it more difficult to clean your teeth. Along with keeping your mouth clean, fluoride has been shown to be critical in the prevention of root caries. We can customize fluoride treatments for you to make sure you are receiving the right amount. Certain foods and snacks can dramatically increase the number of bacteria that forms the decay-causing plaque, making your diet a very important factor. Finding root decay early or susceptibility before it begins is the best way to address the issue. Regular dental visits for cleanings and examinations will serve you well in the long run. Strategies focused on prevention of root decay (like an ADA-accepted sodium fluoride toothpaste, supplemental fluoride rinses and/or gels, xylitol-containing gums and lozenges, alkaline chews and dietary counseling) must be part of the plan of care for most seniors who desire to keep their teeth.

Poor-fitting dentures – What are the problems?

Breakdown of the jawbones:

Typically, over time Jaw bones shrink, unfortunately dentures don’t shrink with them. When a denture no longer fits exactly to the bone as it did when first delivered, more bone destruction occurs at a much faster rate. I have some patients that are proud that they have worn the same set of teeth for 20-30 years but usually we see much greater bone damage than what normally should have occurred. Typically, dentures are made with plastic teeth that tend to wear out after 5-7 years of use. Those who wear the teeth out and continue to use the dentures are at greater risk of bone destruction, especially if the denture opposes natural teeth.

You look older than you are!

Another thing that tends to happen is that you look a lot older. Often a denture wearer that has not replaced a poorly fitting denture has a face that shrinks and appears sunken in. This is increases deep age lines and wrinkles in the skin. Often, a new denture can lengthen the face, and eliminate some of these unwanted features without plastic surgery. A new denture will also help redistribute the forces on your bite and your bone to help protect you from losing the bone support.

Increase risk of undiscovered oral cancer

I am always amazed at how many people think that because they have a set of dentures they no longer need to see a dentist. People without teeth still need to see their dentist on a regular basis for checkups. How often does your physician look in your mouth? There are hundreds of different diseases that occur in the mouth. The most important one to find and to find early is? You guessed it! Cancer. Often it is Not painful and may appear as a red or white sore, bump, or subtle change in the surface tissue. Other signs may include swollen lymph nodes of the neck, difficulty swallowing and speaking. Frequently, oral cancer is not even noticed by the person affected by it until it is too late, often leading to higher mortality rates. This is often true for denture wearers. So please see your dentist for regular oral cancer screenings!

Speech problems

One tell tail sign for many denture wearers is a difficulty in annunciating and forming words. God did not intend for you to speak and eat your food with two pieces of plastic in your mouth. If your dentures move and flop around as you attempt to talk then there is a problem. Proper speech involves your teeth, lips, tongue, cheeks and roof of your mouth. A correctly fitting denture works in harmony with the rest of your mouth to speak properly.

Adhesive Denture Cream/Adhesives and Zinc Poisoning

Denture Adhesive is used by millions of people to secure loose or poorly fitting dentures. Some types of adhesives contain the mineral zinc in the formulation.

In a 2008 journal of Neurology article was published, in which researchers at Texas Southwestern Medical School highlighted the risk of Zinc in denture adhesives. The study found 4 patients that used large amounts of denture cream were found to have abnormally high levels of Zinc in their blood.

Another study performed by a physician at Vanderbilt University noted that 11 of the patients they were treating for crippling nerve damage and low copper levels were found to be using excessive amounts of denture cream containing Zinc. The body needs Zinc to function properly but when you get too much it can deplete your copper levels, as these two minerals compete for absorption into the body. Depleted copper levels can lead to serious and irreversible neurological (brain) problems.

In these cases the affected had been using 2 or more tubes of denture cream a week for a number of years. All of this lead to class action lawsuits against Proctor and Gamble the parent company of the manufacturer GlaxoSmithKlein. In the end, the lawsuits were settled and GlaxoSmithKlein ended production and distribution of the 3 Poligrip products, instead introducing reformulated zinc free products. When using denture adhesive, a 2.4-ounce tube of denture adhesive used by a consumer with upper and lower dentures should last seven to eight weeks. Often, a well-fitting denture will not need any type of adhesive for retention.

Malnutrition

I often say that dentures are not a replacement for teeth, they are a replacement for no teeth. The problem with dentures is that you are adding two large pieces of plastic that move around in place of 32 separate fixed, individualized, specialized chewing devices. When those chewing devices, aka teeth, are lost the bone support that surrounded them resorbs away. Dentures will never be as good as what the good Lord gave you at birth. Dentures made to fit the jawbone initially, in time tend to not fit as well, because the jawbone shrinks and remodels. They begin to slip and wearers end up retraining muscles in the mouth to compensate for this.

When they fit properly, dentures have only 1/6th of the chewing power that natural teeth have. To be honest with you, most denture patients that I have seem do not have properly fitting dentures. It is not a badge of honor or courage to have a set of dentures that is 10–20 years old. How many pairs of shoes do you have that you have worn daily for 10-20 years? So what typically happens in patients with dentures, is that their dentures dictate what they can eat and what they cannot eat. Foods that are too hard to eat are avoided and then there is a psychological component of embarrassment that denture wearers may have, not wanting to be seen having problems chewing or eating their foods.

Nutrition becomes more critical as we get older and most nutritional foods are in the produce aisles of the grocery stores and not all the other isles filled with premade over processed foods. These all tend to be high in sugar, sodium, fat, or have ingredients in them that you cannot even pronounce. None of this is healthy for you! These processed foods tend to be easier to eat.

Fortunately, if you have lost your natural teeth, you no longer have to be condemned to wear a denture the rest of your life. If you have a denture you always have the option to upgrade! Dental implants, which are anchored into the jawbone, can bridge that gap. Now we have many implant supported denture options that vastly improve the retention, fit, and chewing power of a denture and allow you to get back to a more natural diet.

Oral Systemic Connection Considerations

The mouth is the gateway to the body and what happens to one will surely happen to the other. Current research continues to mount, and support the argument that chronic infections in the mouth cause chronic infections in the body, affecting systemic health. According to numerous studies, there are different ways oral disease may affect your overall health.
Over 60 million Americans have periodontal disease at some level with 30% having severe advanced chronic periodontal disease. The health of your gum tissue and your teeth significantly impact the health of your body. Bacteria from the mouth and that cause periodontal disease have been strongly linked to heart disease, stroke risk, and diabetes. If you are already at risk with heart disease or other health problems it becomes even more critical to focus on mouth health.

Let us take a look at heart disease

Heart disease medically is defined as any condition of the heart or vessels around the heart that impairs function to the heart. This includes arrhythmias, vascular disease, angina, atherosclerosis, coronary artery disease, valve disease, myocardial infarction and ischemic stroke. Today, Heart disease is the #1 cause of death in the United States and the #1 killer of women. Half of those who die from heart disease had no signs or symptoms and their cholesterol levels were normal. Usually when a physician sees disease in the coronary arteries, it is already advanced and generalized throughout the body.

The mouth, and in particular the gum tissue is highly vascularized and bacteria have easy access to it. Bacteria live under the gum tissue as plaque surrounding our teeth. As the diagram below shows, bacteria, once in the bloodstream, invade the endothelium, the inner layer of blood vessels, causing them to be inflamed. In time this, through a series of events, weakens the blood vessel walls allowing plaques (lipids) to buildup. This can lead to the rupture of the wall, which in turn causes a clot to form. This can cause either block the vessel or dislodge from the wall leading to a heart attack or a stroke.

Respiratory Implications

Elderly patients can suffer from a weakened immune system or have respiratory diseases such as Chronic Obstructive Pulmonary Disease (COPD) or Emphysema. The saliva in your mouth can contain thousands of bacteria. Some of the bacteria in the gums can adhere to the droplets of water in the air you inhale and exhale when you breathe. These pathogen laden droplets of water can be aspirated into the lungs, causing pneumonia or other pulmonary infections. Cytokines, are inflammatory mediators found in the gums that can also be aspirated into the lungs causing inflammation and breathing complications.

Diabetes risk

Approximately 84 million American Adults are prediabetic, meaning their blood sugar levels are higher than normal but not yet high enough to be diagnosed as having type 2 diabetes. 90% of them don’t know they have it. Insulin is a hormone made by your pancreas that acts like a key to let blood sugar into cells for use as energy. If you have prediabetes, the cells in your body don’t respond normally to insulin. Your pancreas makes more insulin to try to get cells to respond. Eventually your pancreas can’t keep up, and your blood sugar rises, setting the stage for prediabetes—and type 2 diabetes down the road. 30 million Americans or 9.4% of the U.S. population have diabetes.

Those that have diabetes are at an increased risk of developing periodontal disease and those with periodontal disease are at risk of developing diabetes, particularly those that are prediabetic. Numerous strains of bacteria associated with gum disease have been found in many research studies to also cause diabetes or reduce insulin production. Coupled with changes in the diet to more processed foods higher in sugar and carbohydrates, seniors are particularly at risk of developing systemic problems with deterioration of their oral health.
The population in our country continues to live longer and more of those individuals are keeping their teeth. Thus the focus of dentistry needs to put more emphasis on prevention of disease, and restoration and maintenance of existing teeth rather than replacement of lost teeth.

Oral Systemic Connection

Did you know that the health of your mouth can affect the health of your body? Recent scientific research suggests a very strong correlation between chronic oral infections from periodontal (gum) disease and systemic health. Research at major universities and medical centers strongly supports an oral systemic connection. According to published statistics, more that 60 million Americans show signs of periodontal disease, a chronic bacterial infection that affects the gums and bone supporting the teeth. Almost 30% show signs of the more severe disease, chronic periodontitis. We now have reason to believe that the health of your teeth and gums may have a significant effect on the overall health of your body. To “at risk” patients, this added burden could have a complicating effect on their pre-existing medical conditions.

According to numerous studies, there are three ways oral disease may affect your overall health:

First, bacteria from your gums enter the saliva. From the saliva it may adhere to water droplets within the air you inhale each time you breathe. These bacteria laden water droplets may be aspirated into the lungs, potentially causing pulmonary infection and pneumonia. This can be very troublesome for the elderly or those who may suffer from generalized weakened immunity, associated with chronic obstructive pulmonary disease (COPD) or emphysema. Inflammatory mediators found in inflamed gums called “cytokines” can also enter your saliva. As they too are aspirated into the lungs, they have pro-inflammatory effects on the lower airway, which can contribute to further pulmonary complications.

Secondly, bacteria associated with periodontal disease can enter the body’s circulatory system through the gums (periodontium) around teeth and travel to all parts of the body. As the oral bacteria travels, it may cause secondary infections or it may contribute to the disease process in other tissues and organ systems. Finally, inflammation associated with periodontal disease may stimulate a second systemic inflammatory response within the body and contribute to or complicate other disease entities that may have an inflammatory origin such as, cardiovascular disease, diabetes, orthopedic implant failure and kidney disease. New studies have linked specific types of bacteria that cause gum disease with increased risk of Acute Coronary Syndrome. This increases your risk of a sudden Heart attack or Stroke. Whatever the route oral bacterial may influence, it is in every patient’s best interest to maintain their mouth in an optimum state of health.

The trend of good dental health for seniors and keeping their teeth longer is expected to increase, and the number of seniors is expected to keep growing as the “Baby Boomers” begin to cross the threshold out of middle age. Dentistry for older adults will increasingly become focused on prevention, restoration, and maintenance, rather than on replacement.