The most common dental concerns among elderly patients include edentulism (toothlessness, which is reported in one in four Medicare beneficiaries1), xerostomia (dry mouth), periodontal disease, ill-fitting or worn prosthetics, and progressive decay affecting fractured teeth1 (see Figure 5). As many elderly patients endure a combination of these uncomfortable, possibly painful, conditions, it is important for the PCP to inquire about them during the physical exam and the review of symptoms. At each step, a window of opportunity opens to make appropriate recommendations.
Consider, for example, the patient who cannot easily perform daily oral hygiene because of diabetic neuropathy, severe arthritis, previous cerebral vascular accidents with motor deficits, or declining cognitive function.24 For these patients, referrals for occupational therapy evaluation and recommendations for oral hygiene devices can be made, along with instructions to schedule dental cleanings.
Significant Comorbidities
It is important for PCPs to recognize the association between certain diseases and poor oral health. With the progression of age, the risk increases for type 2 diabetes. Among older diabetic patients with periodontitis (and the systemic inflammation associated with it), the difficulty of maintaining glycemic control increases as well.53 Conversely, diabetic patients who are immunocompromised are at elevated risk for periodontitis. In more than 20 years of formal data collection, periodontists have identified and confirmed an anecdotal relationship between diabetes and severe periodontal disease.26
Elderly patients with poor dental health are also at increased risk for chronic kidney disease. Periodontal disease alone increases the risk for nephropathy 1.5-fold to twofold.54Finally, patients’ risk for oral cancer increases with age. Known risk factors for oral cancers include smoking, use of chewing tobacco, alcohol consumption, chronic friction, and exposure to ultraviolet radiation.55 Survival rates for oral cancers are poor, reemphasizing the need for a thorough oral exam during primary care visits.
Other Challenges for Older Patients
Members of ethnic minority groups and lower-income populations, men, patients with cognitive impairment, and persons who never completed high school are the most likely to avoid, discontinue, or lack access to dental services.56 Loss of dental coverage on retirement is associated with a significant decline in elderly patients’ use of dental services. Though now living on a fraction of their preretirement income, millions of retirees are required to pay out-of-pocket for dental services.57
Topical fluoride varnish alone cannot alleviate this multimillion dollar concern, but using it to reinforce retirees’ remaining enamel and prevent caries can help reduce their dental care expenditures. However, until federal and state policymakers act to cover preventive services,2,58 PCPs have little to offer elderly patients beyond oral hygiene education and in-office application of topical fluoride.
Strategies to Reinforce Dental Health
In practices where electronic medical records are in use, a recommendation for dental services should be printed as a patient reminder. Printed recommendations and referrals from PCPs do improve patient compliance.59 In addition to the printed office summary, older patients can be handed a summary of oral health suggestions from the National Institute on Aging, NIH59 (www.nia.nih.gov/health/publication/taking-care-your-teeth-and-mouth).
CONCLUSION
For most Americans with dental health insurance, access to services, and a willingness to practice good oral hygiene, dental care quality is above average. However, health care disparities and a lack of dental coverage prevent millions of Americans from routinely seeking dental services—making it essential for PCPs to promote oral hygiene and offer professional dental referrals with patients of all ages. Topical fluoride varnish, which can reduce the risk for decay as well as progression of existing decay, is an important preventive service that is within the scope of primary care practice.
