Den norske tannlegeforenings Tidende
12.01.2017
Demographic changes and an increasing number of older adults is a big challenge for the oral health care in all the Nordic countries. The risk for dental diseases increases in older populations because morbidity, and reduced daily functioning and cognition complicate oral hygiene practices and the ability to organise dental visits. Futher, many morbidities and multiple drugs have effects on
...salivary flow which increases the risk for dental caries. On the other hand, aging itself has effects on the immune system, increasing the severity of periodontitis and the prevalence of oral mucosal diseases, for example. Consequently, dental diseases seem to be concentrating in older age groups. This article aims to provide a comprehensive overview of the unique aspects of dental diseases among older people, emphasizing the occurrence of root caries and periodontal diseases, which are the main dental diseases that typically involve a large number of dentate older people. It also attempts to describe management strategies and highlights minimally invasive treatment concepts for older people. The number and proportion of older people is growing fast in all industrialised countries. In future, in many countries, most babies born from 2000 may reach 100 years of age if the annual increase in life expectancy continues (1). For example in Finland in 2010, the proportion of those 65 years old or older was 17.5 % and the corresponding proportion has been predicted to be 28.8 % in 2060 (2).
In many western countries the new generations of the older people will be more healthy, more wealthy, better educated and will make greater demands on health services than the older people today. On the other hand, as the number of older people is growing, so also is the number of very old, frail and dependent older people.
Oral health needs will be significantly affected by changes in health status, in attitudes and behaviour. Currently, the oral health of older individuals is improving rapidly, and the number of persons who have retained their own teeth is increasing. The WHO recommendation for adequate occlusion, 20 natural teeth, has almost been achieved in Sweden in the oldest age groups (3) but in Finland the oldest age groups have about 10 teeth (4).
This article aims to give the reader a comprehensive overview about the features of dental diseases among older people, emphasising the occurrence of root caries and periodontal diseases, which are the main dental diseases typically involving large number of dentate older people. It also attempts to describe management strategies and treatment concepts for older people with different degrees of treatability.
Dental caries
Dental caries is an infectious disease caused by acidogenic microorganisms, which dissolve enamel, cementum and dentine. The main risk factors for dental caries among older people are poor oral hygiene, poor diet and hyposalivation (5). There is global trend towards a decrease in untreated caries among children and untreated caries seems to be more prevalent among older populations (6). Globally, there are three peaks in the incidence of caries, at 6, 25 and 70 years, although the incidence and prevalence vary between countries (6). In Finland, the national Health 2011 survey revealed that caries was most common among 75 years old and older age groups. More than half of men and 21 % of women in this age group had at least one tooth with a caries lesion (4).
The location of caries lesions is determined by the retention of microbial deposits (7). Kotsanos and Darling (1991) have reported decreasing susceptibility of enamel to artificial caries with age (8). This was explained by the completion of mineralisation of the outer enamel and by a reduction in the permeability of enamel with age. However, the fluoride content of the mid-coronal buccal surface enamel was found to decrease post-eruptively. This latter observation is in accordance with the finding of Kidd et al. (1984), that the abraded enamel of old individuals develops more extensive artificial caries lesions than does the intact enamel of their younger counterparts (9). It thus seems that the risk of developing enamel caries lesions does not decline with age.
During aging, the dentine becomes more sclerotic, which diminishes the susceptibility of dentine to dental caries (10). This sclerotic dentine with intra-and inter-hypermineralised dentinal tubules, cannot be etched adequately, which reduces the dentinal seal of composite resins. Preparation of retention grooves into the cavity among older people is needed.
Root caries
As a result of periodontal diseases and attachment loss, gingival recessions become frequent in older people (Fig. 1). Exposed root surfaces are more vulnerable to destruction than is the enamel. The root surface is rough, thus retaining more dental plaque than enamel. Root dentine and cement include less unorganic material but more organic material when compared with enamel. Further, hydroxyapatite cristals in root dentine are clearly smaller and few and far between and therefore root dentine is more vulnerable to acid attack (11). As a consequence, in acid attack, mineral on at the root surface is lost at a higher pH and during a longer time when compared with enamel.
Primary demineralisation of root exposes collagen fibrils, which can lead to greater breakdown of dentine (12). Root caries lesions usually spread by covering a large surface area rather than penetrating deeply into tooth structure. Circumferential spreading of root surface caries weakens the tooth structure and increases the risk of crown fractures (Fig. 2).
The prevalence of root caries among older people has been high in most studies on older adults (13 - 15), although Henriksen (2004) concluded that caries was a minor problem in older Norwegians (16). In recent studies, root caries lesions have been associated with previous restorations, most notably prosthetic crowns and with decrease in functional ability and cognitive function (14,17). Frequent sugar intake, poor oral hygiene and use of removable partial dentures have been associated with large increases in the risk of root caries (18). Cumulative gingival recession also increases the risk of root caries by creating more surfaces at risk and by making these areas more difficult to clean adequately.
Splieth et al. (2004) also confirmed an increase in the root caries index (4.6 - 10.6 %) in a longitudinal study on older people in Germany (19). Shah and Sundram (2004) showed in their study that older urban Indians from higher socio-economic groups had higher proportion of carious teeth (2/3 of their lesions were root caries) than rural older Indians in lower socio-economic and literacy groups, contradicting a previous study in Scandinavian older people (13,20). Fure's (2003) longitudinal study on Swedish older people showed that the incidence of coronal caries decreased, while the incidence of root caries increased with age, with highest increase in the oldest age group (21).
Management of caries
In healthy older people, restorative treatment of caries lesions does not differ from that of normal adult patients. With modern restorative materials, a whole treatment concept ought to be based on a philosophy of tissue preservation. However, adhesive bonding can be challenging when only a minimal amount of enamel remains and the bonding is performed on sclerotic dentine. Minimal intervention dentistry (MID) is an evidencebased approach to managing dental caries (22). The principles of MID are described in Table 1. Applying in practice, modified from Brostek & Walsh (2014) (23) by A-M S:
Recognition
When regonising lifestyle factors, daily oral hygiene practices in order to remove dental biofilm are most important. The frequency of tooth brushing and interdental cleaning and the use of fluoridated tooth paste is ascertained and the outcome of cleaning is evaluated. The timing of diet and the content of diet are also investigated. Saliva tests include measuring stimulated and unstimulated salivary flow rate, evaluating buffer capacity, and evaluation of Streptococcus mutans and Lactob
Gå til medietIn many western countries the new generations of the older people will be more healthy, more wealthy, better educated and will make greater demands on health services than the older people today. On the other hand, as the number of older people is growing, so also is the number of very old, frail and dependent older people.
Oral health needs will be significantly affected by changes in health status, in attitudes and behaviour. Currently, the oral health of older individuals is improving rapidly, and the number of persons who have retained their own teeth is increasing. The WHO recommendation for adequate occlusion, 20 natural teeth, has almost been achieved in Sweden in the oldest age groups (3) but in Finland the oldest age groups have about 10 teeth (4).
This article aims to give the reader a comprehensive overview about the features of dental diseases among older people, emphasising the occurrence of root caries and periodontal diseases, which are the main dental diseases typically involving large number of dentate older people. It also attempts to describe management strategies and treatment concepts for older people with different degrees of treatability.
Dental caries
Dental caries is an infectious disease caused by acidogenic microorganisms, which dissolve enamel, cementum and dentine. The main risk factors for dental caries among older people are poor oral hygiene, poor diet and hyposalivation (5). There is global trend towards a decrease in untreated caries among children and untreated caries seems to be more prevalent among older populations (6). Globally, there are three peaks in the incidence of caries, at 6, 25 and 70 years, although the incidence and prevalence vary between countries (6). In Finland, the national Health 2011 survey revealed that caries was most common among 75 years old and older age groups. More than half of men and 21 % of women in this age group had at least one tooth with a caries lesion (4).
The location of caries lesions is determined by the retention of microbial deposits (7). Kotsanos and Darling (1991) have reported decreasing susceptibility of enamel to artificial caries with age (8). This was explained by the completion of mineralisation of the outer enamel and by a reduction in the permeability of enamel with age. However, the fluoride content of the mid-coronal buccal surface enamel was found to decrease post-eruptively. This latter observation is in accordance with the finding of Kidd et al. (1984), that the abraded enamel of old individuals develops more extensive artificial caries lesions than does the intact enamel of their younger counterparts (9). It thus seems that the risk of developing enamel caries lesions does not decline with age.
During aging, the dentine becomes more sclerotic, which diminishes the susceptibility of dentine to dental caries (10). This sclerotic dentine with intra-and inter-hypermineralised dentinal tubules, cannot be etched adequately, which reduces the dentinal seal of composite resins. Preparation of retention grooves into the cavity among older people is needed.
Root caries
As a result of periodontal diseases and attachment loss, gingival recessions become frequent in older people (Fig. 1). Exposed root surfaces are more vulnerable to destruction than is the enamel. The root surface is rough, thus retaining more dental plaque than enamel. Root dentine and cement include less unorganic material but more organic material when compared with enamel. Further, hydroxyapatite cristals in root dentine are clearly smaller and few and far between and therefore root dentine is more vulnerable to acid attack (11). As a consequence, in acid attack, mineral on at the root surface is lost at a higher pH and during a longer time when compared with enamel.
Primary demineralisation of root exposes collagen fibrils, which can lead to greater breakdown of dentine (12). Root caries lesions usually spread by covering a large surface area rather than penetrating deeply into tooth structure. Circumferential spreading of root surface caries weakens the tooth structure and increases the risk of crown fractures (Fig. 2).
The prevalence of root caries among older people has been high in most studies on older adults (13 - 15), although Henriksen (2004) concluded that caries was a minor problem in older Norwegians (16). In recent studies, root caries lesions have been associated with previous restorations, most notably prosthetic crowns and with decrease in functional ability and cognitive function (14,17). Frequent sugar intake, poor oral hygiene and use of removable partial dentures have been associated with large increases in the risk of root caries (18). Cumulative gingival recession also increases the risk of root caries by creating more surfaces at risk and by making these areas more difficult to clean adequately.
Splieth et al. (2004) also confirmed an increase in the root caries index (4.6 - 10.6 %) in a longitudinal study on older people in Germany (19). Shah and Sundram (2004) showed in their study that older urban Indians from higher socio-economic groups had higher proportion of carious teeth (2/3 of their lesions were root caries) than rural older Indians in lower socio-economic and literacy groups, contradicting a previous study in Scandinavian older people (13,20). Fure's (2003) longitudinal study on Swedish older people showed that the incidence of coronal caries decreased, while the incidence of root caries increased with age, with highest increase in the oldest age group (21).
Management of caries
In healthy older people, restorative treatment of caries lesions does not differ from that of normal adult patients. With modern restorative materials, a whole treatment concept ought to be based on a philosophy of tissue preservation. However, adhesive bonding can be challenging when only a minimal amount of enamel remains and the bonding is performed on sclerotic dentine. Minimal intervention dentistry (MID) is an evidencebased approach to managing dental caries (22). The principles of MID are described in Table 1. Applying in practice, modified from Brostek & Walsh (2014) (23) by A-M S:
Recognition
When regonising lifestyle factors, daily oral hygiene practices in order to remove dental biofilm are most important. The frequency of tooth brushing and interdental cleaning and the use of fluoridated tooth paste is ascertained and the outcome of cleaning is evaluated. The timing of diet and the content of diet are also investigated. Saliva tests include measuring stimulated and unstimulated salivary flow rate, evaluating buffer capacity, and evaluation of Streptococcus mutans and Lactob
