JOHCD www.johcd.

org Sep 2013;7(3) 170

Geriatric Dentistry: A Review
Contact Author
Dr Kuldeep Dhanker
[email protected]
J Oral Health Comm Dent 2013;7(3)170-173
1
Senior Lecturer
Department of Public Health Dentistry
School of Dental Sciences, Sharda University,
Greater Noida, UP, INDIA
2
Professor & Head
Department of Public Health Dentistry
Kanti Devi Dental College and Hospital,
Mathura, UP, INDIA
3
Senior Lecturer
Department of Public Health Dentistry
School of Dental Sciences, Sharda University,
Greater Noida, UP, INDIA
4
Senior Lecturer
Department of Public Health Dentistry
Kanti Devi Dental College and Hospital,
Mathura, UP, INDIA
ABSTRACT
Education in geriatric medicine is in its infancy in India and geriatric dentistry is nonexistent. Poor oral health is linked to
serious systemic diseases such as cardiovascular diseases and stroke. Edentulousness and paucity of prosthodontic
rehabilitation prevent the elderly from choosing food that they like and deny them the pleasure of eating, which is
essential for a feeling of wellbeing.Oral mucosal diseases and lesions are common in elderly people. Many older adults
have pigmented and benign soft-tissue and hard-tissue conditions. Lichenoid mucosal lesions can also be caused by a
variety of medications commonly prescribed in older patients. The prevalence of leukoplakia and lichen planus in
older people ranges from 1.0 to 4.8% and 1.1 to 6.6%, respectively. Fifty percent of zoster patients over 60 years of
age will develop postherpetic neuralgia that may persist for months or even years.Root surface caries result from an
age-related condition that develops on cementum following gingival recession or as an extension of existing coronal
caries onto the root surface coronal caries are also quite prevalent among older persons. A recent survey of 6574-
year-old in Madagascar observed that the mean number of DMFT was 20.2. In China, second national oral health
survey revealed that the mean number of decayed and filled teeth was 2.5 at old age, and study in India confirmed this
figure observed in China, the mean number of decayed teeth being 2.5. Denture stomatitis is a common oral mucosal
lesion of clinical importance in old-age populations. The prevalence rate of stomatitis is reported within the range of
1167% in complete denture wearers. Other major denture-related lesions include denture hyperplasia and traumatic
ulcer; their prevalence rates in old-age denture wearers range from 4 to 26%.
Keywords: Geriatric population, Quality of life, Prosthetic need, Denture satisfaction
INTRODUCTION
K
nowledge of human behaviour
is a requirement in all branches
of health and oral health espe-
cially public health dentistry and pediatric
dentistry. As people live longer they be-
come elder. The physiological processes of
ageing and the gradual diminution in acu-
ity of the five senses are facts, but the rate
at which they occur shows great variation
(1).
The global population is increasing at an
annual rate of 1.2%, while the population
of those 65 years or older is increasing at a
rate of 2.3%. About 600 million people
are currently aged 60 years or older, and
this number is expected to double up by
2025. By 2050, there will be 2 billion older
people, 80% of them living in developing
countries (2).
The growing proportion of the elderly is
attributed mainly to the decrease in mor-
tality rates among older people and overall
decline in birth rates. The World Oral
Health Report 2003 emphasizes that oral
diseases are age related, that the risk factors
for chronic disease are common to most
oral diseases, and that oral health is an in-
tegral part of general health and an impor-
tant component of Quality of life (QOL).
Chronic diseases are more prevalent in the
older population, whose age-associated
physiological changes may deprive them
of their mobility and independence (2).
India is a vast country with a population
of more than 1.2 billion. Of this, people
older than 60 years constitute 7.6%, which
in actual number is 76 million. Incidence
of oral cancer, which is considered an old
age disease, is highest in India. Preventive
dental care is almost nonexistent to the
rural masses and very limited in urban.
Above all, there is no orientation of dental
REVIEW ARTICLE
Dhankar K
1
, Ingle NA
2
, Chaudhary A
3
, Kaur N
4
Journal of Oral Health
Community Dentistry
&
171 JOHCD www.johcd.org Sep 2013;7(3)
graduates towards the special needs of geri-
atric population. Recommendation in-
cludes education on geriatric population,
diploma, certificate in geriatric dentistry,
provision of various preventive and cura-
tive treatments for various oral diseases of
the elderly (3).
However, the link among oral health, sys-
temic disease, and quality of life in the eld-
erly needs to be better-defined. There is
some evidence in the literature that indi-
cates that coronal and root caries appear to
be major health problems for the elderly
(4).
Developing countries elders who are cur-
rently most in need of oral care are the
poor and disabled. Geriatric dentistry
should receive increased emphasis in the
nations dental schools, specifically in
predoctoral dental curricula (5).
Fortunately, loss of teeth because of peri-
odontitis is unusual among elderly peo-
ple, no matter how frail, and a recent sys-
tematic review of existing evidence con-
cluded that the connections between poor
oral hygiene, periodontitis and tooth loss
are very uncertain. Nonetheless, plaque con-
tinues to cause chronic marginal gingivitis,
which is almost endemic in this popula-
tion (6).
There is a paucity of basic data on oral health
care and knowledge and perception and past
dental experience of elderly in India.
By keeping these points in mind and with
the help of various literatures a review is
being made to throw some light on the
following objectives.
To evaluate the need of geriatric den-
tistry in India
To assess dental health of elderly
population and evaluate their attitude
regarding dental health and disease.
HISTORY AND NEED FOR SPECIAL-
ISED CARE FOR GERIATRIC POPU-
LATION IN INDIA
In 1972, a World Health Organization
(WHO) commission concluded that edu-
cation is inextricably interwoven with the
health services system. This statement
cannot have more direct implication than
in the field of geriatric dentistry. Patient
and community health outcome is shown
to be directly related to the education of
health practitioners. Quality of health care
by graduates, especially to the elderly, is likely
to be related to their education. Without
firsthand experience of growing old and
adequate knowledge of social, psychologi-
cal, and economic aspects of growing old,
the dentist will be prone to errors, espe-
cially of omission. It has been reported
that the attitude of dental students towards
elderly patients is more or less neutral when
regular dental curriculum is followed. Un-
less education in care of the elderly was
included, it is difficult to change students
attitude from neutral to positive for better
health care delivery(1).
A few unique facts regarding the elderly
population in India include the following:
The rate of growth of the elderly popu-
lation is faster than that of the general
population.
There is a larger proportion of women
among the elderly (52% of the >60
years and >55% of the >80 years age
groups).
Eighty per cent of the elderly popula-
tion resides in rural areas.
Nine per cent of the elderly live alone
or with persons other than their im-
mediate family members.
Nearly 75% of the elderly are economi-
cally dependent, with little difference
between the urban and rural elderly.
Three-fourths of the dependent eld-
erly population is supported by their
own family members.
Thirty per cent of the elderly are below
the poverty line. Only 53.5% of the
urban elderly and 37% of the rural eld-
erly possess some kind of financial as-
sets.
Only 28% of the elderly population is
literate (low compared with the national
average).
In India, the elderly population suffers
from numerous dental and oral health
problems. The Government of India an-
nounced a National Policy for Older Per-
sons (NPOP) in January 1999, which aimed
to provide financial, food, health and shel-
ter security. Several schemes such as provi-
dent funds, pensions and gratuity, etc. pro-
vide financial security in old age. However,
there is no social and financial security plan
for workers in unorganized sectors such as
farm labourers, daily wage earners, etc. The
National Old Age Pension Scheme covers
only 1% of the elderly population and the
amount given is a paltry Rs 75150 per
month (3).
According to estimates, about 50% of
schoolchildren are suffering from Dental
caries and more than 90% of adults are
having periodontal diseases. The use of
tobacco products, smoking or smokeless
form, are widely prevalent in our country.
Hence, oral pre-cancers and cancers are
emerging as major threat to younger peo-
ple and are increasing to alarming propor-
tion in India(7).
Among the elderly in 65-74 yrs age group,
the DCI survey reported caries prevalence
to be about 70% while the multi-centric
oral health survey reported it to be 51- 95%
in various states. Higher prevalence (100%)
of gingival bleeding in 65-74 years was re-
ported from few states (Orissa, Rajasthan)
in the multi-centric oral health survey.
The loss of attachment (3 mm or more)
was 96% in 65-74 years old in Maharashtra
in the multi-centric oral health survey. The
DCI study has reported prevalence of loss
of attachment for 65-74 years as 60.7%,
which is comparatively lower than found
in the multi-centric oral health survey. As
per the multi-centric oral health survey
complete edentulousness was reported to
be maximum (18.5%) in Delhi, which was
comparable with the DCI data, which re-
ported complete edentulousness in 19.9%.
The lowest level of edentulousness was
reported from Arunachal Pradesh in only
16 subjects (1.0%). Of 18.5% edentulous
subjects in Delhi, about half of them
(9.8%) were using complete dentures while
there were no denture wearers in Arunachal
Pradesh. In Rajasthan, though the preva-
lence of complete edentulousness was
10%, only 0.1% had complete dentures (8).
The interrelationship between oral health
GERIATRIC DENTISTRY: A REVIEW
JOHCD www.johcd.org Sep 2013;7(3) 172
and general health is particularly pro-
nounced among older people. Poor oral
health can increase the risks to general health
and with compromised chewing and eat-
ing abilities, affect nutritional intake. Simi-
larly, systemic diseases and/or the adverse
side effects of their treatments can lead to
increased risk of oral diseases, dry mouth
and altered sense of taste and smell. The
high prevalence of multimedication thera-
pies in advanced age may further compli-
cate the impact on oral health and oral health
care (9).
The predominant oral health problems of
the elderly include dental caries, periodon-
tal disease, dry mouth (xerostomia), tooth
wear and oral cancer. Recurrent caries around
failing restorations, cervical caries (around
the neck of the tooth) or root caries are the
most common dental caries in the elderly.
The prevalence of periodontal disease ap-
pears to increase with age, which may re-
flect an accumulation of disease over time
rather than enhanced susceptibility. The
number of teeth that need to be extracted
due to periodontal disease increases with
age. The progressive impact of smoking
and drinking on the development of soft
tissue lesions is more apparent in older
adults, and the prevalence of oral cancer
increases with age (10).
Patients with oral mucosa diseases suffer
from severe and life threatening symptoms,
preventing them from eating and drink-
ing, and influencing daily life in many ways.
Oral health problems can result in pain and
discomfort and can lead to problems in
eating, interpersonal relationships, appear-
ance and an individuals positive self-im-
age.
Llewellyn and Warnakulasuriya evaluated
stomatological diseases (keratosis, ulcers,
lichen planus, candidiasis, dry mouth, burn-
ing mouth, temporomandibular disorders
and pain) using the OHIP-14, finding that
diseases of the oral mucosa can have a seri-
ous impact on the patients oral quality of
life. Hegarthy et al. found that increase in
pain evaluated by VAS score was associ-
ated with poor oral health-related quality
of life in patients with lichen planus. Pain
is an important factor in limiting oral and
other everyday functions in patients.
Tambolli S et al. in 2009 studied the quality
of life and psychological problems in pa-
tients with oral mucosa disease, finding
that oral mucosal conditions radically af-
fected HRQoL and were accompanied by a
very high frequency of psychological prob-
lems. Mumcu et al. Observed worse oral
health-related quality of life in patients with
Behets disease and recurrent aphthous
stomatitis, and in patients with active oral
ulcers compared with ulcer-free ones(11).
STRATEGIES TOWARDS IMPROVING
ORAL HEALTH OF OLDER PEOPLE
Globally, important mechanisms for bet-
ter oral health would relate to strengthen-
ing oral health policy development; na-
tional capacity building within oral health
care for the underserved; education and
training for service and care for the elderly,
and research for oral health. However, the
challenges vary from country to country and
region to region; the differences are par-
ticularly notable between developed and
developing countries (9).
ORAL HEALTH POLICY
As emphasized in the World Oral Health
Report 2003, WHO sees oral health as in-
tegral to general health and as a determi-
nant for quality of life? The interrelation-
ship between oral health and general health
is particularly pronounced among older
people primarily because several oral dis-
eases have risk factors in common with
chronic diseases. Today, few countries have
clearly stated policies and goals specifically
for oral health promotion and oral health
care for older people. Generally speaking,
oral health policies and programmes should
be an integral part of national and com-
munity health programmes. Thus, in many
countries developing and developed
strengthened analysis for policy and analy-
sis of policy are urgently needed for advo-
cacy, legislation, goal setting, and design of
public oral health programmes for old-age
persons(9).
Oral health planners and administrators are
encouraged to use the common risk fac-
tors approach to integrate interventions for
oral health among older adults into gen-
eral health programmes. A benefit of this
approach is the focus on improving health
conditions for the whole population as well
as high risk groups such as older adults,
thereby alleviating inequities(9).
FACTORS INFLUENCING EATING
ABILITY OF ELDERS
Ronald J. Hunt carried out the study as
there was need for data on edentulism and
oral health problems in free living popula-
tion of elderly people so that more defini-
tive conclusion can be drawn for planning
and policy purposes in Iowa countries. The
study concluded that elderly people tend
to underestimate their treatment needs. It
may be that these people expect to have
some problem with their dentures and ac-
cept these problems without feeling a need
to seek treatment (12).
R. J. Hawkins carried out the study to de-
termine the relative contribution of dental
caries and periodontal disease as reasons
for indicating tooth extraction among nurs-
ing home residents and independently liv-
ing adults in Canada. This study concluded
that tooth extraction in elderly population
was more due to caries as a major reason.
Whereas, both periodontal condition and
caries continue to be the causative factor
for the tooth loss, as periodontitis con-
tributes in tooth loss affecting more than
20% of older adults (13).
PROSTHETIC NEED AND DENTURE
SATISFACTION
Miyazaki H. carried out a study to assess
the oral health condition and denture treat-
ment needs in institutionalised elderly peo-
ple in Japan. The study concluded that the
dentition were in terminal stage with re-
gard to oral diseases among institutional-
ised elderly people. The higher level of
untreated teeth and denture treatment need
and poor oral hygiene were found in eld-
erly people with poor general health than
in those with better health. A two way sys-
tem for oral health care should be planned;
i.e. one is the provision of oral care serv-
ices for elderly population, second a pro-
gram for oral disease prevention in younger
generation (14).
GERIATRIC DENTISTRY: A REVIEW
173 JOHCD www.johcd.org Sep 2013;7(3)
A Mersel carried out a study to evaluate the
extent of denture satisfaction in Israeli eld-
erly one year or more after prosthesis place-
ment and explore the effect of age, gender,
marital status and medical status upon
denture acceptance in Israeli. The study con-
cluded that Israeli elders were mostly satis-
fied with their denture after 1 yr of use.
The denture satisfaction in Israeli elderly
people depends on various aspects such as
marital status, presence of systemic dis-
ease, immigration history, physiological dis-
order and chronological age. This study
also made clinician to consider these vari-
ables prior to new denture fabrication in
order to prognostic outcome (15).
ORAL HEALTH AND QUALITYOF
LIFE
A. J. Hassel carried out a study to obtain
information about the subjective oral health
status of non clinical elderly population
of urban regions of Germany, one in east
and one in west by using OHIP14 and for
first time the GOHAI and further more to
compare the results obtained by use of
both instruments in Germany. The study
concluded that GOHAI score for this ran-
domly chosen non clinical group enable
comparison with scores measured in fu-
ture. When focusing more on subjective
oral health, reflecting minor clinical changes
or assessing more immediate functional
aspects, the GOHAI seems more appro-
priate in this collectively. When researchers
are additionally e.g. interested in these sin-
gle aspects, for e.g. happiness with appear-
ance, the GOHAI is more appropriate than
the OHIP (16).
Hugo FN carried out a study to achieve
objective was to evaluate if poor oral sta-
tus was associated with lower ratings in
WHO QOL-BREF domain i.e. physical,
psychological, social relations and environ-
ment. The study has random sample of
872 persons of more than 60 yrs of age
from municipality registers. The study con-
cluded that oral states may cause suffering
and impact on general QOL This study
suggests that independent living older per-
son without teeth or not satisfied with their
own ability to chew food have an increase
chance of reporting a poorer QOL in gen-
eral as assesses with WHO QOL BREF
(17).
Kim H-Y carried out a study to assess the
association of chewing ability to OHRQOL
measured by OHIP 14 controlling for clini-
cal oral health status, self reported health
status, demographic factors and socioeco-
nomic condition among community dwell-
ing and institutionalised Korean elders.
The study concluded that there was highly
significant association between chewing
ability and OHRQOL measured by
OHIP14 score, after controlling related fac-
tors. The ability to chew effectively a wide
variety of food may facilitate the pleasur-
able sensation of foods, social context of
sharing a meal with others, and health ben-
efits of a diverse diet. Amelioration of chew-
ing ability might independently contribute
in improving OHRQOL of elders (18).
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GERIATRIC DENTISTRY: A REVIEW