The health challenges faced by older Americans are important for you to know
Tremendous improvements in public health, research, and technology have enabled today’s older Americans to enjoy healthier and longer lives than previous generations. These advancements have changed our lifestyles and our national demographics. People over the age of 65 will have increased in number from what was approximately 3 percent of our nation’s inhabitants in 1900 to a projected 20 percent by the year 2020. Familiarity with the diseases, medications, and challenges of the elderly and their impact on dental health, as well as the provision of dental services, is increasingly important to dental professionals.
Studies by the National Institute of Aging indicate that physical activity, mental stimulation, not smoking, moderate alcohol use, healthy dietary habits, social support, and routine healthcare contribute to maintaining aging wellness and functional independence. With increased awareness of disease prevention and health promotion strategies, and their contributions to longer life, more seniors are modifying their behaviors to enhance longevity.
Yet, in spite of our scientific advancements and more wholesome lifestyles choices:
* 57 percent of men and 61 percent of women ages 65-74 have high blood pressure
* Approximately 70 percent of people with arrhythmias are between the ages of 65 and 85
* Greater than one-half of people over age 70 suffer from some form of arthritis
* Almost 85 percent of people who die of coronary heart disease are aged 65 and older
* 2.1 million people, or 1 percent of the U.S. population, have rheumatoid arthritis
* 89 percent of stroke deaths occur in people age 65 and older
* Periodontal disease and its responsible pathogens have been linked epidemiologically and immunologically with coronary artery disease, peripheral vascular disease, cerebrovascular disease, and pneumonia
* More than 2 million people endure symptoms of Sjogren’s Syndrome, while 40 million Americans suffer from xerostomia
Senior healthcare and medications
Americans are living longer while utilizing a wide variety of pharmaceuticals to better manage chronic diseases and improve the quality of their lives. Studies show elderly patients may be seeing multiple healthcare providers who are often prescribing multiple medications. Vitamins, herbs, and supplements are frequently self-prescribed and consumed without the healthcare provider’s knowledge. According to IMS Health, a healthcare industry and pharmaceutical resource, prescription volume in the United States has increased by 25 percent during the past three years. More than 3.2 billion prescriptions were dispensed in 2001, with most older Americans taking both prescription and over-the-counter medicaments. Individuals in long-term care facilities - about 5 percent of the elderly population - take an average of eight drugs per day.
Comprehensive understanding of the more commonly prescribed drugs associated with the elderly is vital to individualized patient pharmacological appraisal and successful long-term dental care. Knowledge of drug selectivity, classification, dosage, mechanism of action, routes of administration, absorption, and excretion are important components of a thorough patient medical health history review. As dental professionals concerned with understanding the aging process, we strive to appreciate the systemic and oral changes experienced by many older adult patients. The challenge is to successfully integrate the complications from patient medications into our diagnosis and treatment planning processes.
Oral health and medications
Saliva is integrally linked to oral health. It is necessary to aid in wound healing, maintaining neutral oral pH, remineralization of incipient caries, lubrication of both the soft and hard tissues, assistance in taste, chewing and swallowing, and to minimize the microbial content and food debris in the oral cavity. The absence of adequate saliva (salivary hypofunction) increases a patient’s risk for serious oral diseases.
Although the major salivary glands undergo histological degeneration with advancing age, the production of saliva is not dramatically diminished with aging. In the absence of salivary gland tumors or systemic disease, it is generally the use of medications - and more frequently their side effects - that result in the reduction of saliva.
Dental professionals have long emphasized the importance of adequate water consumption and proper diet, coupled with immaculate oral hygiene, to assist patients suffering from the symptoms of salivary hypofunction. And while radiation therapy, chemotherapy, nutritional deficiencies, dehydration, and endocrine disorders contribute to dry mouth, more than 700 medications listed in the Physician’s Desk Reference specify xerostomia as a side effect. Many of these drugs are routinely ingested by the elderly, including diuretics, anti-hypertensives, painkillers, tranquilizers, anti-histamines, and anti-depressants.
Depression is a major public health problem affecting an estimated 6 million men annually, with research suggesting that men die by suicide at four times the rate of women. According to the Center for Advancement of Health, an affiliate of the National Health and Medical Research Council of Australia Clinical Fellowship, late-life depression occurs more often in women, but has greater negative outcomes for men.
Currently there are four classes of drugs used to treat depression:
* Tri-cyclics/polycyclics (TCA’s)
* Monoamine oxidase inhibitors (MAOI’s)
* Selective serotonin reuptake inhibitors (SSRI’s)
* Tetracyclics
All four classes of drugs are known to cause xerostomia. Simply educating patients on proper diet, increased fluid intake, and optimal oral hygiene may not be sufficient to treat the symptoms of drug-induced xerostomia, particularly when substitution of the offending drug may be unlikely.
Treatment suggestions for xerostomia
With patients suffering from dry mouth, dental professionals should be watchful of rampant decay, halitosis, and Candidiosis, symptoms typically more aggressive in xerostomic patients.
In severe cases of salivary hypofunction, the dorsum of the tongue may appear fissured and depapillated. Glossodynia (burning tongue) is another painful symptom usually treated with corticosteroids or analgesics, in addition to recommendations of avoiding acidic and spicy foods. Meticulous oral hygiene and minimally abrasive dentifrices should be recommended, including limitations to sugar consumption. Several companies manufacture non-alcohol mouth rinses, sugarless chewing gums, toothpastes, and lubricating oral gels or sprays to either stimulate salivary flow or enhance patient comfort. Some dental professionals recommend topical fluoride, varnish applications, and desensitizers to minimize root caries and sensitivity, while a minority of patients successfully utilizes salivary substitutes. Relieving our patient’s symptoms is our greatest professional challenge.
While there is no single method of treating dry mouth, we can hopefully make recommendations to increase our patient’s comfort and improve their oral health. Modifying a patient’s brushing habits by incorporating twice-daily use of the Sonicare toothbrush can improve oral hygiene and provide relief from xerostomia. In a study conducted at Tufts University, comparing the ability of the Sonicare toothbrush and a manual toothbrush to stimulate salivary flow in women with Sjogren’s Syndrome, at 30 and 45 minutes post brushing, the Sonicare group exhibited between 130 percent and 230 percent greater salivary flow than the manual group. In a follow-up questionnaire, 93 percent of subjects used the Sonicare specifically for increased salivary flow and 88 percent stated they were still using their Sonicare three years later.
Summary
The fastest growing age group in the United States, those over 65, is the group with the greatest percentage of chronic diseases. Prescription medications taken by the elderly to minimize the impact of these diseases present clinical treatment challenges to dental professionals. Drug-induced salivary hypofunction should be at the top of every clinician’s differential diagnosis when evaluating and treating any patient within this age group. The importance of thorough oral and pharmacological assessment, combined with toothbrush modification, can successfully decrease the ravages of drug-induced xerostomia.
A graduate of the University of Alaska, Anchorage Community College Dental Hygiene Program, Gail B. Stoops has been active in curriculum projects and course development protocol for oral health education with the National Institute of Health, the National Institute of Dental Research-Science Transfer Task Force, the Thomas Jefferson University’s Allied Health Training Grant, and Philips Oral Healthcare. Gail served nine years on the American Dental Hygienists’ Association board of trustees, including the position of president in 1996. She currently practices dental hygiene part-time and resides in northern Arizona.
