Oral health not only refers to the absence of dental diseases but its contribution to general well-being and quality of life (QoL), which is more difficult to achieve with advancing age (Lamster and Northridge, 2008). Learning about the characteristics of this population can give helpful insights into oral health care for the elderly and how to modify approaches to suit individual needs.
Demography of Aging: Australia and New Zealand
Due to medical advances, socioeconomic development and improved public health measures, the average lifespan has improved and mortality/fertility rates have reduced. In New Zealand (NZ) the number of people aged 65+ doubled between 1991 and 2020, to reach 790,000. This number is projected to double again by 2056 with a significant increase in the 85+ age group, which will be approximately 320,000 in 2048 (Stats NZ, 2021). In Australia, from 1999 to 2019, the population of those aged 65+, increased from 12.3% to 15.9%, with a 2.5% increase in the age group 85+ in the same period (Australian Bureau of Statistics, 2019).
The New Zealand 2018 census results show that the changing demography consists of a more diverse cultural makeup (Statistics NZ, 2021). Furthermore, poor oral health statistics are represented disproportionally in both countries by the indigenous population and minority groups. Collectively, these statistics highlight the burden on oral health services because more people are living longer and are more likely to retain natural teeth. However, the elderly population is made up of distinct groups and this can affect the way a treatment plan is formulated. Below are the estimated age groups and their different characteristics:
65-74 are considered as young elderly who are relatively healthy and active
75-84 are mid-elderly who could vary from being healthy and active to being dependent with chronic diseases
85+ are the frail group with one or more medical conditions
(Razak, Jose Richard, Thankachan, Abdul Hafiz, Nanda Kumar, Sameer, 2014).
Senior Living Spectrum
All elderly are not subject to the same living circumstances. We must appreciate the wide spectrum of senior living and levels of senior care (National Caregivers Library, 2019). At one end of the spectrum are individuals who are more independent, perhaps requiring some form of home assistance, but who are able to carry out dental homecare themselves. Even so, there may be opportunities for oral health practitioners to make suggestions for an improved homecare routine with a focus on preventative strategies. On the other end of the spectrum individuals may live in aged-care facilities in which healthcare assistants and/or nurses provide the necessary care. Moreover, in institutionalised facilities care resistant behaviours may be more common and add further complications. Evidence reveals that institutionalised individuals are at greater risk of developing dental diseases than the non-institutionalised, as reported in a study of several rest homes in Adelaide in 2005 (Lamster and Northridge, 2008).
Determinants of Oral Health in Elderly
Treating the elderly population poses many challenges for oral health professionals especially when implementing preventative strategies. Clinicians have to consider deterioration of physical and mental health, medical condition(s) and polypharmacy when managing this cohort. The elderly population is a unique group of vulnerable individuals who become the main consumers of primary health care services and are more likely to access multiple services such as medical clinics, outpatient hospital services, pharmacies, dental care and supportive care (Lamster and Northridge, 2008). Oral health practitioners in collaboration with allied health services can achieve better oral health outcomes and continuation of care.
With individuals keeping their natural teeth further into life there is a greater need for support, preventative dental treatment and restorative work. The oral-health concerns during ageing can include one or more of the following:
Reduced chewing efficiency
Poor nutritional status
Denture-related issues - such as ill fitting, damaged/cracked dentures
Edentulism or tooth loss
Reduced sensitivity to pain
Reduced salivary function or xerostomia
Changes in teeth such as erosion, attrition and recession
Changes in oral mucosa - less regenerative capacity
Coronal Dental caries - higher rate
Root caries - higher rate
Periodontal disease - more prevalent
Complications by comorbid conditions such as hypertension, heart disease, cancer and diabetes mellitus
Age-related physiologic changes
(Razak et al., 2014; Gil-Montoya, Ferreira de Melli, Barrios, Gonzalez-Moles, Bravo, 2015)
Other factors that can affect oral health in the elderly are barriers to accessing dental care resulting in irregular dental visits due to cultural views, ethnic background, inability to travel, fear and anxiety, and financial strain.
Recommendations for oral health interventions and other suggestions:
Diet and nutrition counselling should be considered as an integral part of the oral health assessment. Refer to GP, nutritionist or dietician if necessary
Toothbrushing: Use an electric toothbrush with an ergonomic handle. This makes it easier to grip and move around. Alternatively, the way you hold a toothbrush can be changed (refer to resource below) as well as the shape and size of the handle to suit individual needs. Soft or extra soft bristled toothbrushes with bass or modified bass brushing technique using light pressure are best
Mouth rinses: either fluoride rinses or chlorhexidine rinses can help control plaque and prevent decay - important for those with physical or mental disability. A small bottle spray can help if the individual is unable to swish around the liquid
Adaptive dental aids: special handles for floss, toothbrush or interdental aids
Water flossing - not a replacement to flossing but helps those with reduced dexterity
Use high fluoride toothpaste
Apply fluoride varnish regularly
Communicate: Keep oral health instructions simple, use easy to understand language and visual aids. Speak at a volume they can hear clearly but not raising your voice
Counsel and educate caregivers or families to support with homecare
Provide denture care instructions
Use tell-show-do method
Employ preventative counselling
Make referrals to other health care professionals as required
Work with allied health professionals
(Razak et al., 2014; Lamster and Northridge, 2008).