GERIATRIC DENTISTRY AND PREVENTION: RESEARCH AND PUBLIC POLICY (REACTION PAPER) C. MEYEROWITZ
The University of Rochester, Department of Clinical Dentistry, 601 Elmwood Avenue, Box 705, Rochester, New York 14642-00024 Adv Dent Res 5:74-77, December, 1991
Abstract—The population of older adults is heterogeneous and can be divided into many subgroups: the young-old, the old-old, the healthy, the sick, the frail, the mentally and physically handicapped, the ambulatory, the chair-bound, house-bound or institution-bound, and the economically advantaged and disadvantaged. This diversity is extremely important to the discussion of the oral health needs, preventive health strategies, and research agenda for the elderly. As life expectancy increases, more attention is being paid to disease prevention so that the quality of life in old age can be improved. However, the link among oral health, systemic disease, and quality of life in the elderly needs to be better-defined. There is some evidence in the literature that indicates that coronal and root caries appear to be major health problems for the elderly. This needs to be corroborated in longitudinal studies. Although periodontal disease prevalence and severity are high in some subgroups of the elderly, these appear to be in decline in the general population. Dental health-care workers must be cognizant of the oral conditions associated with systemic disease and the use of medication, a major concern in older adults. Prevention of oral disease in the elderly requires early intervention, education of the dental health team, and innovative uses of well-established preventive agents such as fluoride. An extensive research effort is needed to answer basic and applied questions regarding the oral health needs of the elderly. Federal and private funding will be necessary. The dental profession will have to demonstrate and be persuasive that money spent on research and care for the elderly is money well spent.
Presented during "Prevention Revisited", a Symposium at Eastman Dental Center's 75th Anniversary Celebration, Rochester, NY, September 13-14,1990
74
I
t is widely accepted that the population of the United States is aging. Dr. Gershen correctly points out that the proportion of people over 65 years of age is increasing and that the largest increases are occurring in individuals over 85 years of age. The magnitude of the potential health issue facing us in the future is illustrated by the actual numbers of individuals in these categories rather than percentages: Americans over age 65 are projected to increase in number from 25 million in 1980 to 67 million by 2040, with the population 85 years or older increasing from 1 to 5% of the total population and numbering over 13 million (Bureau of the Census, 1982). When we discuss the oral health needs and preventive health strategies in older adults, it is important to recognize that this population is extremely heterogeneous, falling into many subgroups: the young-old, the old-old, the healthy, the sick, the frail, the mentally and physically handicapped, the ambulatory, and the chair-bound, house-bound or institution-bound (Wilentz et al., 1986). To this list can be added the economically advantaged and the economically disadvantaged. There is a greater diversity in an elderly population than in a younger cohort. The elderly do not constitute a monolithic group. In considering, as Dr. Gershen does, the oral condition and health of the elderly, the prevention of disease, research direction, and public health policy, this diversity must be kept in mind. For example, by definition, older people do not necessarily have bad oral or general health (Gift, 1988). Those in good health have health care needs very similar to those of healthy young adults. Clearly, there are those who have major health care needs, and perhaps we should be focusing on those groups. Dr. Gershen points out that, as life expectancy increases, more attention is being paid or should be paid to disease prevention in order to improve the quality of life in old age. It is germane to oral health prevention—and indeed to justify public health dollar expenditure—for the dental profession to demonstrate that the overall quality of life of older individuals (or younger ones, for that matter) is improved by good oral health or by dental care. There is a paucity of data in this area (Miller, 1987). To a large extent, we in the dental profession accept, sometimes without adequate question, that good oral health is vital to a person's well-being and, therefore, worth financial expenditure. However, there is limited empirical evidence to support this assumption (Thims etal., 1987). Numerous studies indicate that the elderly themselves do not rank oral health high among their health concerns (Marinelli et al., 1982; Manne and Mehra, 1983). There is also a poor relationship between objectively determined need for dental services and perceived need; i.e., older adults do not perceive the same need for dental care in themselves that dentists do (Branch etai, 1986). There is often a lack of understanding of the relationship between oral health and other health concerns, both in the elderly and among health professionals. The importance of good oral health to
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diabetic control or in the immune-compromised individual has been established in case studies and by accredited reports; however, many health professionals, both dentists and physicians, are not as vigilant in this area as they could be. Dr. Gershen has described the common oral conditions that occur in older adults and mentioned preventive strategies for minimizing these. Tooth loss is clearly a feature of older adults but appears to be declining. A similar trend is evident for edentulousness. However, this is occurring differentially across the older population; those below the poverty level and with less education have a higher prevalence of edentulousness and fewer teeth than older adults from middle and upper socio-economic groups (Ismail et aL, 1987; Baum, 1981). It is unfortunate that the elderly in lower socio-economic groups are also more likely to have other health problems, less likely to practice preventive health, and more likely to have financial barriers to receiving care (Gift, 1988). On a positive note, the trend evident over the past two decades of an improvement in the socio-economic status of older individuals is projected to continue over the next several decades. Similarly, oral health status and preventive practices are projected to improve (Douglass and Gammon, 1985; Beck, 1984). Despite these encouraging projections for the future, it is estimated that 40% of older adults in the United States will fall into a "special-needs" category because of their health status or due to physical and economic barriers which limit their access to care (Gift, 1988). The relationship of partial or complete loss of the dentition to impairments in masticatory function has, as Dr. Gershen points out, been well-established (Chauncey et a/., 1981; Wayler and Chauncey, 1983). However, significant adaptation to a compromised dentition can occur in the elderly (Feldman et aL, 1980). The literature on the relationship of a decreased ability to chew and adequate nutrition or gastric disease is equivocal (Ettinger, 1987). However, studies suggest that older people who retain their teeth have enhanced self-esteem and thus a sense of an improved quality of life (Kiyak and Mulligan, 1987; Berkey etaL, 1985). As Dr. Gershen points out, coronal and root caries appear to be major dental problems for the elderly, as indicated in a number of prevalence studies and the 1985-86 NIDR survey of oral health. There are, however, very few reports of longitudinal studies of caries in the older population. A recent 18-month report of coronal and root caries in a non-institutionalized elderly population reports high caries incidence rates comparable with those found in schoolchildren (Hand et aL, 1988). These findings need to be corroborated in other studies. It is of interest that recurrent caries rates in this study were relatively low, accounting for only 12% of new coronal and root lesions. Similar recurrent caries rates in older individuals were reported in an earlier Swedish study, and these were the same as present in younger and middle-aged adults. The nature of the periodontal status of older adults is complex. Dr. Gershen mentioned that periodontitis prevalence and severity apparently increase as individuals age. However, the type of periodontitis found in older adults progresses slowly and infrequently (Page, 1984). Older adults may indeed not have an enhanced susceptibility to periodontal disease but rather display the features of a disease process which reflects the accumulation
75
of lesions over time. There is a building consensus based on various studies that, whereas periodontal prevalence and severity are high in some subgroups of the elderly, the decline in periodontal disease seen in the general population will be reflected in a similar decrease in the elderly (Beck, 1984; Page, 1984). The Adult Survey (NIDR, 1987) tends to corroborate the view that the prevalence of advanced periodontitis is probably quite low in the older population and will continue to decline. As is the case for caries, incidence studies of periodontal disease are lacking and need to be done. Oral cancer, as Dr. Gershen described, is indeed a disease affecting older adults. Miller (1974) reported an almost linear increase in lip cancer from ages 45 to 85, with even higher rates in the 85-and-over age group. Cancer of the tongue shows a slower but progressive linear rise, with little variation in the older groups. Intra-oral cancer exhibits rates similar to those for cancer of the tongue up to age 49, with substantial increases in the 85-and-older group. The assumption that the number of oral cancer cases will increase as the population increases appears reasonable; however, the impact of a reduction in the use of known risk factors (such as alcohol and tobacco) in higher socioeconomic groups could affect this prediction. A major area of concern mentioned in Dr. Gershen's paper is the oral conditions associated with systemic diseases and the use ofmedications. Gift (1988) mentions that there are 120physical or mental diseases in the elderly which affect the oral cavity or oral health behavior. Some of the more important of these include diminished agility and movement, diminished salivary flow secondary to Sjogren's syndrome and the use of medication, diabetes, psychosis and affective disorders, neurological disorders, and chronic and acute pain. The prevalence of most of these conditions increases with age, but it must be remembered that older persons are not by definition in poor general health (Blau, 1982; Halpert and Zimmerman, 1986). To illustrate this, we know that there are a number of oral conditions which have traditionally been thought to be associated with aging. These include decreased salivary flow, atrophic changes of the epithelium, and a reduction in taste function. However, recent evidence indicates that factors such as poly-pharmacy, poor nutrition, or systemic disease are implicated rather than aging per se (Baum, 1986; Bartoshuk, 1988; Hill, 1984). Dr. Gershen makes the important observation that the prevention of oral disease in the elderly requires early intervention, beginning in childhood and continuing throughout adult life. That early intervention (in this case, environmentally applied) is important is well-illustrated by the recent observations that root and coronal caries rates are reduced in older adults who have life-long exposure to fluoridated water as compared with those from non-fluoridated areas (Hunt et aL, 1989; Stamm et aL, 1990). The same benefits of early intervention are suggested by the observation that the decrease in the proportion of the population with gingivitis is associated with significant improvements in oral hygiene, as demonstrated by improved plaque control. This may translate into significant future reductions in inflammatory periodontal disease in the elderly (Page, 1984). In the case of oral cancer, early detection and then intervention could have a significant positive effect on
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the low survival rates noted for oral cancer (Katz and Meskin, 1986). Early detection or diagnosis of systemic conditions, or the use of medications which have oral manifestations, can allow for appropriate oral health prevention or treatment. Examples include the use of fluorides, antimicrobials, and dietary intervention in people with salivary diseases such as Sjogren's syndrome or those who use hyposalivatory medication which leads to significant reductions in salivary flow and an enhanced susceptibility to dental caries. Similarly, detection and appropriate treatment in medical conditions where oral conditions can influence systemic disease are crucial. Antibiotic coverage to prevent bacterial endocarditis in cardio-valvular disease and optimal oral health free of sources of infection in patients who are immunocompromised are some examples where the prevention of serious systemic health complications can result (Gift, 1988). I agree with Dr. Gershen's comment that the dental health team can play an important part in preventing oral disease or the systemic complications of oral infection in certain disease states. This is particularly true in the examples mentioned above— namely, oral cancer detection and treatment of oral infection. However, as he describes, the elderly have the lowest dental service utilization of any age group, despite the recent increase seen in their use of dental services (Antczak and Branch, 1985; Jack, 1986). Unfortunately, those who need it the most—the poor, the medically compromised, those with less education, and ethnic minorities—have the lowest rates of dental care utilization. This is coupled with poor health prevention, behavior, and a high prevalence of those risk factors which predispose them to poor general and oral health (Hayward et al., 1989; Lubben et al, 1989). We need to improve our delivery of care to these groups, perhaps by reaching out to them. Of course, this requires adequate health reimbursement mechanisms, which are often lacking for this population despite improvements in the socio-economic status of older Americans in general (Gift, 1988; Social Security Administration, 1985). Dr. Gershen makes the important point that self-care practices—including brushing, flossing, the use of fluorides, and consumption of diets low in refined carbohydrates—are as important for the elderly as for the rest of the population. Clearly, there need to be modifications for those who have physical limitations. In addition to the use of specially designed toothbrushes, innovative preventive delivery systems need to be considered in this population. Examples include the use of fluoride varnishes, controlled-release devices to deliver fluoride and antimicrobials, and the use of mouthrinses or swabs, all of which may be useful or appropriate for this population (Mandel, 1989; Banting, 1984). The attitudes, knowledge, and beliefs of older adults are related to oral health behavior in the same way as occurs in younger adults (Diehnelt and Kiyak, 1984). Many of the elderly believe that nothing can be done to improve their oral health, possibly because of outdated information or a lack of preventive orientation early in their lives (Gift, 1988). This may change as the current middle-aged adults age, since they tend to be more informed and prevention-oriented than the previous generations. It appears that older adults can still benefit from oral health education which emphasizes self-reliance (Kiyak and Mulligan,
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1987). This has the advantage of improving oral health status while enhancing self-esteem and improving the quality of life (Ettinger, 1987). Despite this, many health professionals, both physicians and dentists, believe that "it's too late" to influence oral health behavior in the elderly (Gift, 1979). Clearly, the frail and severely physically and medically compromised cannot always effectively maintain their own oral health. In these populations, low-compliance preventive measures—such as antimicrobials and fluoride, administered in mouthrinses, swabs, or in controlled-release devices—can be advantageous (Zero, 1990). It is evident from Dr. Gershen's discussion of a research agenda for the elderly that there are many important questions that need to be answered regarding the oral health status of the elderly and the relationship between oral health and general health. It should be emphasized in the planning of this research that the many subgroups present in the elderly should be taken into account. Possibly the greatest difficulty in a climate of dwindling resources will be the task of prioritizing this research effort. Certainly we need more incidence studies of caries and periodontal disease in older adults, among the many subgroups previously mentioned, particularly in relation to salivary status, medication usage, and medical conditions. Clinical trials of preventive agents and approaches for reducing root caries and periodontitis are necessary. We need to know more about the relationship of oral and general health and require a broad-based basic science approach to the issues of risk factors for oral diseases, disease susceptibility in the aging, and innovative preventive strategies. There needs to be a careful look at behavioral issues related to provider-patient attitudes and interaction, barriers to care, and other sociodemographic and psychological factors which affect the oral health of the elderly. These and other important research areas have been mentioned by Dr. Gershen. He makes the important point that they will require a massive influx of Federal and private funding, an unlikely event given the current climate of cost containment. We in the dental profession must, as he points out, be involved in the national health care debate. But to do so, we need to come to it armed with data that stand up to careful scrutiny and demonstrate the value of oral health in its widest sense to the well-being of the elderly. If it can be shown that good oral status is important to psychological well-being, enhances the quality of life of the individual, and has a direct and positive association with general health, advocates for the inclusion of dentistry, and geriatric research in particular, in future health plans will be better prepared to enter into the public debate. Dentistry needs to be able to demonstrate—and, of course, be persuasive—that money spent on research and care for the elderly is money well-spent and that prevention of oral disease in the elderly is a desirable national goal which will have a positive financial benefit as well as improve the quality of life of the older members of our population.
REFERENCES ANTCZAK, A.A. and BRANCH, L.G. (1985): Perceived Barriers to the Use of Dental Services by the Elderly, Gerodontics 1:194-198. BANTING, D.W. (1984): Dental Caries in the Elderly,
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Gerodontology 3:55-61. BARTOSHUK,L.M. (1988): Clinical Psychophysics of Taste, Gerodontics 4:249-255. B AUM, B. J. (1981): Characteristics of Participants in the Oral Physiology Component of the Baltimore Longitudinal Study of Aging, Community Dent Oral Epidemiol 9:128-134. BAUM, B.J. (1986): Salivary Gland Function During Aging, Gerodontics 2:61-64. BECK, J.D. (1984): The Epidemiology of Dental Disease in the Elderly, Gerontology 3:5-15. BERKEY, D.B.; CALL, R.L.; and LOUPE, MJ. (1985): Oral Health Perceptions and Self Esteem in Non-institutionalized Older Adults, Gerodontics 1:213-216. BLAU, Z.S. (1982): Socioeconomic Variations in Dental Status and Behavior of Today's Elderly, Spec Care Dent 2:244-251. BRANCH, L.G.; ANTCZAK, A.A.; and STASON, W.B. (1986): Towards Understanding the Use of Dental Services by the Elderly, Spec Care Dent 6:38-41. BUREAU OF THE CENSUS (1982): Projections of the Population of the United States: 1982-2050 (Advance Report Series), p. 25, No. 922, National Nursing Home Survey 1979. National Center for Health Statistics. CHAUNCEY, H.H.; KAPUR, K.K.; FELLER, R.P.; and W A YLER, A.H. (1981): Altered Masticatory Function and Perceptual Estimates of Chewing Experience, Spec Care Dent 1:250-255. DIEHNELT, D. andKIYAK, H. A. (1984): Predictions of Oral Health Behaviors Among Elderly Japanese Americans, / Dent Res 63:213. DOUGLASS, C.W. and GAMMON, M.D. (1985): Implications of Oral Disease Trends for the Treatment Needs of Older Adults, Gerodontics 1:51-58. ETTINGER, R.L. (1987): Oral Disease and its Effect on the Quality of Life, Gerodontics 3:103-106. FELDMAN, R.S.; KAPUT, K.K.; ALMAN, J.E.; and CHAUNCEY, H.H. (1980): Aging and Mastication: Changes in Performance and in the Swallowing Threshold with Natural Dentition, / Am Geriatric Soc 28:97-103. GIFT, H.C. (1979): The Seventh Age of Man: Oral Health and the Elderly, J Am Coll Dent 46:204-215. GIFT, H.C. (1988): Issues of Aging and Oral Health Promotion, Gerodontics 4:194-206. HALPERT, B.P. and ZIMMERMAN, M.K. (1986): The Health Status of the "Old-Old": A Reconsideration, Soc Sci Med 2:893-899. HAND, J.S.; HUNT, R.J.; and BECK, J.O. (1988): Incidence of Coronal and Root Caries in an Older Adult Population, J Public Health Dent 48:14-19. HAYWARD, R.A.; MEETZ, H.K.; SHAPIRO, M.F.; and FREEMAN, H.E. (1989): Utilization of Dental Services: 1986 Patterns and Trends, / Public Health Dent 49:147152. HILL, M.W. (1984): The Influence of Aging on Skin and Oral Mucosa, Gerontology 3:34-45. HUNT, R.J.; ELDREDGE, T.B.; and BECK, J.D. (1989): Effect of Residence in a Fluoridated Community on the Incidence of Coronal and Root Caries in an Older Adult
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Population, J Public Health Dent 49:138-141. ISMAIL, A.I.; BURT, B.A.; HENDERSHOT, G.E.; JACK, S.; and CORBIN, S.B. (1987): Findings From the Dental Care Supplement of the National Health Interview Survey, JAmDentAssoc 114:617-621. JACK, S.S. (1986): Use of Dental Services. United States, 1983. NCHS Advance Data, No. 122, Washington, DC: DHHS. KATZ, R.V. and MESKIN, L.H. (1986): The Epidemiology of Oral Diseases in Older Adults. In: Geriatric Dentistry, P. Holm-Pedersen and H. Loe, Eds. Copenhagen: Munksgaard, pp. 221-237. KIYAK, H.A. and MULLIGAN, K. (1987): Studies of the Relationship Between Oral Health and Psychological Wellbeing, Gerodontics 3:109-112. LUBBEN, J.E.; WEILER, P.G.; and CHI, J. (1989): Health Practices of the Elderly Poor, Am J Public Health 79:731 734. MANDEL, I.D. (1989): Preventive Dental Services for the Elderly, Dent Clin North Am 33:81-90. MANNE, S. and MEHRA, R. (1983): Accuracy of Perceived Treatment Needs Among Geriatric Denture Wearers, Gerodontology 2:67-71. MARINELLI, R.D.; SREEBNY, L.M.; and KAMEN, S. (1982): Perception of Dental Needs by the Well Elderly, Spec Care Dent 2:161-164. MILLER, A.B. (1974): The Epidemiology of Oral Cancer, / Can Dent Assoc 3:211-217. MILLER, W.A. (1987): Does Oral Health Influence Quality of Life? Introductory remarks to a symposium held at the Gerontological Society of America, New Orleans, 1985, Gerodontics 3:99. NIDR (1987): Oral Health of United States Adults: The National Survey of Oral Health in U.S. Employee Adults and Seniors: 1985-1986. NIH Publication No. 87-2868. PAGE, R.C. (1984): Periodontal Diseases in the Elderly: A Critical Evaluation of Current Information, Gerodontology 3:63-70. SOCIAL SECURITY ADMINISTRATION (1985): Income of the Population 55 and Over, 1984. Office of Research Statistics and International Policy. STAMM, J.W.; BANTING, D.W.; and IMREY, P.B. (1990): Adult Root Caries Survey of Two Similar Communities with Contrasting Natural Water Fluoride Levels, J Am Dent Assoc 120:143-149. THINES, T.; KARUZA, J.; and MILLER, W.A. (1987): Oral Health Impact on Quality of Life: Methodological and Conceptual Concerns, Gerodontics 3:100-102. WAYLER, A.H. and CHAUNCEY, H.H. (1983): Impact of Complete Dentures and Impaired Natural Dentition on Masticatory Performance and Food Choice in Healthy Aging Men, / Prosthet Dent 49:427-433. WILENTZ, J.S.; ADELSON, R.; KLEINMAN, D.V.; and BADINELLI, J. (1986): A Plan for Oral Health Research in Aging: A Collaborative Project of the National Institute on Aging, the National Institute of Dental Research and the Veterans Administration, Gerodontics 2:208-211. ZERO, D.T. (1990): Personal communication.
The University of Rochester, Department of Clinical Dentistry, 601 Elmwood Avenue, Box 705, Rochester, New York 14642-00024 Adv Dent Res 5:74-77, December, 1991
Abstract—The population of older adults is heterogeneous and can be divided into many subgroups: the young-old, the old-old, the healthy, the sick, the frail, the mentally and physically handicapped, the ambulatory, the chair-bound, house-bound or institution-bound, and the economically advantaged and disadvantaged. This diversity is extremely important to the discussion of the oral health needs, preventive health strategies, and research agenda for the elderly. As life expectancy increases, more attention is being paid to disease prevention so that the quality of life in old age can be improved. However, the link among oral health, systemic disease, and quality of life in the elderly needs to be better-defined. There is some evidence in the literature that indicates that coronal and root caries appear to be major health problems for the elderly. This needs to be corroborated in longitudinal studies. Although periodontal disease prevalence and severity are high in some subgroups of the elderly, these appear to be in decline in the general population. Dental health-care workers must be cognizant of the oral conditions associated with systemic disease and the use of medication, a major concern in older adults. Prevention of oral disease in the elderly requires early intervention, education of the dental health team, and innovative uses of well-established preventive agents such as fluoride. An extensive research effort is needed to answer basic and applied questions regarding the oral health needs of the elderly. Federal and private funding will be necessary. The dental profession will have to demonstrate and be persuasive that money spent on research and care for the elderly is money well spent.
Presented during "Prevention Revisited", a Symposium at Eastman Dental Center's 75th Anniversary Celebration, Rochester, NY, September 13-14,1990
74
I
t is widely accepted that the population of the United States is aging. Dr. Gershen correctly points out that the proportion of people over 65 years of age is increasing and that the largest increases are occurring in individuals over 85 years of age. The magnitude of the potential health issue facing us in the future is illustrated by the actual numbers of individuals in these categories rather than percentages: Americans over age 65 are projected to increase in number from 25 million in 1980 to 67 million by 2040, with the population 85 years or older increasing from 1 to 5% of the total population and numbering over 13 million (Bureau of the Census, 1982). When we discuss the oral health needs and preventive health strategies in older adults, it is important to recognize that this population is extremely heterogeneous, falling into many subgroups: the young-old, the old-old, the healthy, the sick, the frail, the mentally and physically handicapped, the ambulatory, and the chair-bound, house-bound or institution-bound (Wilentz et al., 1986). To this list can be added the economically advantaged and the economically disadvantaged. There is a greater diversity in an elderly population than in a younger cohort. The elderly do not constitute a monolithic group. In considering, as Dr. Gershen does, the oral condition and health of the elderly, the prevention of disease, research direction, and public health policy, this diversity must be kept in mind. For example, by definition, older people do not necessarily have bad oral or general health (Gift, 1988). Those in good health have health care needs very similar to those of healthy young adults. Clearly, there are those who have major health care needs, and perhaps we should be focusing on those groups. Dr. Gershen points out that, as life expectancy increases, more attention is being paid or should be paid to disease prevention in order to improve the quality of life in old age. It is germane to oral health prevention—and indeed to justify public health dollar expenditure—for the dental profession to demonstrate that the overall quality of life of older individuals (or younger ones, for that matter) is improved by good oral health or by dental care. There is a paucity of data in this area (Miller, 1987). To a large extent, we in the dental profession accept, sometimes without adequate question, that good oral health is vital to a person's well-being and, therefore, worth financial expenditure. However, there is limited empirical evidence to support this assumption (Thims etal., 1987). Numerous studies indicate that the elderly themselves do not rank oral health high among their health concerns (Marinelli et al., 1982; Manne and Mehra, 1983). There is also a poor relationship between objectively determined need for dental services and perceived need; i.e., older adults do not perceive the same need for dental care in themselves that dentists do (Branch etai, 1986). There is often a lack of understanding of the relationship between oral health and other health concerns, both in the elderly and among health professionals. The importance of good oral health to
VOL.
5
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diabetic control or in the immune-compromised individual has been established in case studies and by accredited reports; however, many health professionals, both dentists and physicians, are not as vigilant in this area as they could be. Dr. Gershen has described the common oral conditions that occur in older adults and mentioned preventive strategies for minimizing these. Tooth loss is clearly a feature of older adults but appears to be declining. A similar trend is evident for edentulousness. However, this is occurring differentially across the older population; those below the poverty level and with less education have a higher prevalence of edentulousness and fewer teeth than older adults from middle and upper socio-economic groups (Ismail et aL, 1987; Baum, 1981). It is unfortunate that the elderly in lower socio-economic groups are also more likely to have other health problems, less likely to practice preventive health, and more likely to have financial barriers to receiving care (Gift, 1988). On a positive note, the trend evident over the past two decades of an improvement in the socio-economic status of older individuals is projected to continue over the next several decades. Similarly, oral health status and preventive practices are projected to improve (Douglass and Gammon, 1985; Beck, 1984). Despite these encouraging projections for the future, it is estimated that 40% of older adults in the United States will fall into a "special-needs" category because of their health status or due to physical and economic barriers which limit their access to care (Gift, 1988). The relationship of partial or complete loss of the dentition to impairments in masticatory function has, as Dr. Gershen points out, been well-established (Chauncey et a/., 1981; Wayler and Chauncey, 1983). However, significant adaptation to a compromised dentition can occur in the elderly (Feldman et aL, 1980). The literature on the relationship of a decreased ability to chew and adequate nutrition or gastric disease is equivocal (Ettinger, 1987). However, studies suggest that older people who retain their teeth have enhanced self-esteem and thus a sense of an improved quality of life (Kiyak and Mulligan, 1987; Berkey etaL, 1985). As Dr. Gershen points out, coronal and root caries appear to be major dental problems for the elderly, as indicated in a number of prevalence studies and the 1985-86 NIDR survey of oral health. There are, however, very few reports of longitudinal studies of caries in the older population. A recent 18-month report of coronal and root caries in a non-institutionalized elderly population reports high caries incidence rates comparable with those found in schoolchildren (Hand et aL, 1988). These findings need to be corroborated in other studies. It is of interest that recurrent caries rates in this study were relatively low, accounting for only 12% of new coronal and root lesions. Similar recurrent caries rates in older individuals were reported in an earlier Swedish study, and these were the same as present in younger and middle-aged adults. The nature of the periodontal status of older adults is complex. Dr. Gershen mentioned that periodontitis prevalence and severity apparently increase as individuals age. However, the type of periodontitis found in older adults progresses slowly and infrequently (Page, 1984). Older adults may indeed not have an enhanced susceptibility to periodontal disease but rather display the features of a disease process which reflects the accumulation
75
of lesions over time. There is a building consensus based on various studies that, whereas periodontal prevalence and severity are high in some subgroups of the elderly, the decline in periodontal disease seen in the general population will be reflected in a similar decrease in the elderly (Beck, 1984; Page, 1984). The Adult Survey (NIDR, 1987) tends to corroborate the view that the prevalence of advanced periodontitis is probably quite low in the older population and will continue to decline. As is the case for caries, incidence studies of periodontal disease are lacking and need to be done. Oral cancer, as Dr. Gershen described, is indeed a disease affecting older adults. Miller (1974) reported an almost linear increase in lip cancer from ages 45 to 85, with even higher rates in the 85-and-over age group. Cancer of the tongue shows a slower but progressive linear rise, with little variation in the older groups. Intra-oral cancer exhibits rates similar to those for cancer of the tongue up to age 49, with substantial increases in the 85-and-older group. The assumption that the number of oral cancer cases will increase as the population increases appears reasonable; however, the impact of a reduction in the use of known risk factors (such as alcohol and tobacco) in higher socioeconomic groups could affect this prediction. A major area of concern mentioned in Dr. Gershen's paper is the oral conditions associated with systemic diseases and the use ofmedications. Gift (1988) mentions that there are 120physical or mental diseases in the elderly which affect the oral cavity or oral health behavior. Some of the more important of these include diminished agility and movement, diminished salivary flow secondary to Sjogren's syndrome and the use of medication, diabetes, psychosis and affective disorders, neurological disorders, and chronic and acute pain. The prevalence of most of these conditions increases with age, but it must be remembered that older persons are not by definition in poor general health (Blau, 1982; Halpert and Zimmerman, 1986). To illustrate this, we know that there are a number of oral conditions which have traditionally been thought to be associated with aging. These include decreased salivary flow, atrophic changes of the epithelium, and a reduction in taste function. However, recent evidence indicates that factors such as poly-pharmacy, poor nutrition, or systemic disease are implicated rather than aging per se (Baum, 1986; Bartoshuk, 1988; Hill, 1984). Dr. Gershen makes the important observation that the prevention of oral disease in the elderly requires early intervention, beginning in childhood and continuing throughout adult life. That early intervention (in this case, environmentally applied) is important is well-illustrated by the recent observations that root and coronal caries rates are reduced in older adults who have life-long exposure to fluoridated water as compared with those from non-fluoridated areas (Hunt et aL, 1989; Stamm et aL, 1990). The same benefits of early intervention are suggested by the observation that the decrease in the proportion of the population with gingivitis is associated with significant improvements in oral hygiene, as demonstrated by improved plaque control. This may translate into significant future reductions in inflammatory periodontal disease in the elderly (Page, 1984). In the case of oral cancer, early detection and then intervention could have a significant positive effect on
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the low survival rates noted for oral cancer (Katz and Meskin, 1986). Early detection or diagnosis of systemic conditions, or the use of medications which have oral manifestations, can allow for appropriate oral health prevention or treatment. Examples include the use of fluorides, antimicrobials, and dietary intervention in people with salivary diseases such as Sjogren's syndrome or those who use hyposalivatory medication which leads to significant reductions in salivary flow and an enhanced susceptibility to dental caries. Similarly, detection and appropriate treatment in medical conditions where oral conditions can influence systemic disease are crucial. Antibiotic coverage to prevent bacterial endocarditis in cardio-valvular disease and optimal oral health free of sources of infection in patients who are immunocompromised are some examples where the prevention of serious systemic health complications can result (Gift, 1988). I agree with Dr. Gershen's comment that the dental health team can play an important part in preventing oral disease or the systemic complications of oral infection in certain disease states. This is particularly true in the examples mentioned above— namely, oral cancer detection and treatment of oral infection. However, as he describes, the elderly have the lowest dental service utilization of any age group, despite the recent increase seen in their use of dental services (Antczak and Branch, 1985; Jack, 1986). Unfortunately, those who need it the most—the poor, the medically compromised, those with less education, and ethnic minorities—have the lowest rates of dental care utilization. This is coupled with poor health prevention, behavior, and a high prevalence of those risk factors which predispose them to poor general and oral health (Hayward et al., 1989; Lubben et al, 1989). We need to improve our delivery of care to these groups, perhaps by reaching out to them. Of course, this requires adequate health reimbursement mechanisms, which are often lacking for this population despite improvements in the socio-economic status of older Americans in general (Gift, 1988; Social Security Administration, 1985). Dr. Gershen makes the important point that self-care practices—including brushing, flossing, the use of fluorides, and consumption of diets low in refined carbohydrates—are as important for the elderly as for the rest of the population. Clearly, there need to be modifications for those who have physical limitations. In addition to the use of specially designed toothbrushes, innovative preventive delivery systems need to be considered in this population. Examples include the use of fluoride varnishes, controlled-release devices to deliver fluoride and antimicrobials, and the use of mouthrinses or swabs, all of which may be useful or appropriate for this population (Mandel, 1989; Banting, 1984). The attitudes, knowledge, and beliefs of older adults are related to oral health behavior in the same way as occurs in younger adults (Diehnelt and Kiyak, 1984). Many of the elderly believe that nothing can be done to improve their oral health, possibly because of outdated information or a lack of preventive orientation early in their lives (Gift, 1988). This may change as the current middle-aged adults age, since they tend to be more informed and prevention-oriented than the previous generations. It appears that older adults can still benefit from oral health education which emphasizes self-reliance (Kiyak and Mulligan,
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1987). This has the advantage of improving oral health status while enhancing self-esteem and improving the quality of life (Ettinger, 1987). Despite this, many health professionals, both physicians and dentists, believe that "it's too late" to influence oral health behavior in the elderly (Gift, 1979). Clearly, the frail and severely physically and medically compromised cannot always effectively maintain their own oral health. In these populations, low-compliance preventive measures—such as antimicrobials and fluoride, administered in mouthrinses, swabs, or in controlled-release devices—can be advantageous (Zero, 1990). It is evident from Dr. Gershen's discussion of a research agenda for the elderly that there are many important questions that need to be answered regarding the oral health status of the elderly and the relationship between oral health and general health. It should be emphasized in the planning of this research that the many subgroups present in the elderly should be taken into account. Possibly the greatest difficulty in a climate of dwindling resources will be the task of prioritizing this research effort. Certainly we need more incidence studies of caries and periodontal disease in older adults, among the many subgroups previously mentioned, particularly in relation to salivary status, medication usage, and medical conditions. Clinical trials of preventive agents and approaches for reducing root caries and periodontitis are necessary. We need to know more about the relationship of oral and general health and require a broad-based basic science approach to the issues of risk factors for oral diseases, disease susceptibility in the aging, and innovative preventive strategies. There needs to be a careful look at behavioral issues related to provider-patient attitudes and interaction, barriers to care, and other sociodemographic and psychological factors which affect the oral health of the elderly. These and other important research areas have been mentioned by Dr. Gershen. He makes the important point that they will require a massive influx of Federal and private funding, an unlikely event given the current climate of cost containment. We in the dental profession must, as he points out, be involved in the national health care debate. But to do so, we need to come to it armed with data that stand up to careful scrutiny and demonstrate the value of oral health in its widest sense to the well-being of the elderly. If it can be shown that good oral status is important to psychological well-being, enhances the quality of life of the individual, and has a direct and positive association with general health, advocates for the inclusion of dentistry, and geriatric research in particular, in future health plans will be better prepared to enter into the public debate. Dentistry needs to be able to demonstrate—and, of course, be persuasive—that money spent on research and care for the elderly is money well-spent and that prevention of oral disease in the elderly is a desirable national goal which will have a positive financial benefit as well as improve the quality of life of the older members of our population.
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