The Oral Health of the Long-Term Care Patient
Many oral conditions adversely affect a resident’s nutrition and general health status, and the mouth, in turn, reflects many systemic problems. Advanced periodontitis—fairly common in the elderly—-reduces the ability to chew, exacerbates problems in the control of types 1 and 2 diabetes, and has been found to be a risk factor in pneumonia, cardiovascular disorders, and stroke. Loss and nonreplacement or inadequate replacement of missing teeth causes major nutritional difficulties. Smoking has been identified as a major risk factor for periodontitis, in addition to increasing susceptibility to oral cancer. Oral signs of AIDS are frequently misdiagnosed because many health practitioners are unaware of its presence in the elderly population. The multiple medications taken by many long-term care patients are often the cause of xerostomia (dry mouth), and some cause gingival enlargement. Many of the effects of oral disease may be prevented or treated by appropriate measures when a long-term care facility provides the resources and staff training. (Annals of Long-Term Care: Clinical Care and Aging 2000;8[12}:41-46)
Introduction
The oral health of a resident in a long-term care facility affects many aspects of the individual’s daily life, health, and sense of well-being. The mouth is involved in a wide range of activities, including eating, smiling, speaking, singing, smoking, and kissing. Any changes in oral health are likely to have multiple effects. This is further complicated by the functional and cognitive impairment and diminished cooperation of some residents in the performance of oral hygiene, by the reduced availability of dental care in many nursing homes compared with independent living, and by the lack of financial resources to pay for dental care. This article has three objectives:
1. Describe the oral and dental health changes that may affect the rest of the body and how these effects occur.
2. Describe the various ways that existing systemic conditions and diseases may affect the mouth.
3. Suggest practical ways to improve the oral health of long-term care residents. Oral health changes that may cause local problems and affect the rest of the body include periodontitis and other gingival conditions, dental caries, tooth loss and nonreplacement, inadequate replacement of missing teeth, salivary changes, mucocutaneous conditions, and oropharyngeal neoplasms. Some of these cause continuous or intermittent discomfort; some affect the patient’s nutritional status by making chewing difficult or impossible; others are responsible for self-consciousness and loss of self-esteem; and still others are significant risk factors for serious systemic problems.
Periodontitis
Periodontitis is a chronic inflammatory disease of the gingiva and supporting tissues. If untreated, it results in the progressive loss of bone support around the teeth, the opening of a separation (“pocket”) between gum and tooth, and increasing tooth mobility.1 Bacteria in dental plaque are considered to be the principal causative agents. Pain is not a prominent feature of early disease, and patients are often unaware of the condition until it is pointed out by a dentist or hygienist, teeth become noticeably loose, or abscesses develop. Most adults have some form of the disease, and about 10-20% of the population has moderate or advanced periodontitis. Since residents in long-term care facilities are often in their 70s and beyond, periodontal disease in those who still have their teeth has generally existed for many years and is often advanced.2 Treatment usually slows or stops the progression of the disease (Figures 1A and 1B).
Effects of Periodontitis
One obvious effect of advanced periodontal disease is on nutrition. Patients with many loose teeth or missing teeth are often unable to chew any but the softest foods. They have a tendency to swallow mouthfuls unchewed rather than endure uncomfortable chewing. Such inadequate mastication may result in choking and sometimes in digestive problems. The problem may be worse in residents who have existing swallowing difficulties, such as following a stroke. Chewing difficulties may persist even after loose teeth are removed if they are not replaced with a dental prosthesis or are inadequately replaced.3,4
Another long-recognized effect of periodontitis is its role in the presence of diabetes. Glucose levels in patients with type 1 or 2 diabetes with active, advanced periodontal disease are more difficult to manage than in patients without periodontal disease. Conversely, when the diabetic state is uncontrolled, the patient is more susceptible to periodontal abscesses and rapid periodontal breakdown.5
In the past decade, other effects of periodontitis have become apparent. Evidence is accumulating that the presence of periodontal infections increases susceptibility to pneumonia and other lung conditions,6 cardiovascular disease,7 and stroke. (In a younger population, women of childbearing age with severe periodontitis appear to be at higher risk for preterm birth and low-birth-weight babies.) The mechanism of these effects is still uncertain. It is apparent, however, that the treatment of periodontal disease is advisable at every age level to prevent such complications.
Gingival Enlargement
At least three different types of medication produce gingival overgrowth that can interfere with chewing.8 These are the anticonvulsant phenytoin, the immunosuppressant cyclosporine, and calcium channel blockers, such as nifedipine and diltiazem. The mechanism of the overgrowth is still unclear. The enlargement may be minimal and barely noticeable, or it may be so advanced that the tissue covers the teeth. The effect is cumulative: a patient on cyclosporine who is also given nifedipine often presents with greater gingival overgrowth than with either drug alone (Figure 2). In addition to having difficulty chewing, the patient may be self-conscious and withdrawn because of the unpleasant appearance of the mouth.
Dental Caries
Caries is generally thought of as a disease of young people because the highest incidence of new-enamel decay occurs during the first three decades of life in the enamel on the chewing surfaces and the proximal surfaces (the surface at which each tooth contacts its neighbor). However, older adults are susceptible to root caries, a condition in which decay invades the exposed roots of teeth and may result in pain, tooth fracture, abscess formation, and pulp death, requiring root canal treatment or extraction.9
Tooth Loss and Non-replacement
The nonreplacement of missing teeth is one of the principal causes of inability to chew. Many older people, especially those with low incomes, fail to have lost teeth replaced for financial reasons. They rarely have dental insurance once they are no longer employed. If many teeth are missing, chewing becomes more and more difficult, and malnutrition is likely to result. A related problem is the continued use of dentures that no longer fit properly. The patient either leaves the dentures out of the mouth or uses them only intermittently. Even when a partial denture fits well, the patient is at higher risk for root caries unless the denture is removed daily, and both the denture and teeth are cleaned thoroughly.10,11
Salivary Changes
There has been a longstanding consensus in the health care community that patients in the over-65 age group have a diminished salivary flow. This has recently been questioned, and it now appears that much of the “dry mouth” problem is related to multiple medications taken by the people in this age group. 12 More than 500 drugs in 42 drug categories produce xerostomia. They include antihypertensives, psychotropics, antihistamines, antiarrhymics, and many others. Dry mouth is also caused by Sjögren’s syndrome (an autoimmune condition seen primarily in women that involves dryness of mouth, eyes, and most other mucous membranes), as well as by radiation therapy for cancer of the head and neck. The reduced level of salivary flow increases susceptibility to root caries. Dry mouth tends to make eating less enjoyable and makes swallowing of relatively dry foods difficult. Again, nutritional problems may result.
Mucocutaneous Conditions
There are a number of ulcerative, desquamative conditions that cause the oral tissues to be painful and make eating a highly unpleasant experience. They include candidiasis (thrush), erosive lichen planus, herpes zoster (shingles), and mucous membrane ulcerations resulting from chemotherapy.13
Neoplasms
Approximately one-half of the 30,000 cases of oral cancer reported each year are found in patients over 65 years of age.14 Many deaths from this disease could be averted by early detection during routine screenings.
Systemic Conditions That Affect the Mouth
HIV is a condition not usually associated with older age groups, yet approximately 11% of patients with AIDS are 50 years of age and older, and one-fourth of these are over 60. Changes in the mouth are among the more frequently found signs of HIV and AIDS. These include Kaposi’s sarcoma, candidiasis, necrotic periodontitis, and hairy leukoplakia of the tongue. Many health care practitioners are only vaguely aware or are unaware of the possibility of HIV in an older patient, and the disease often is undiagnosed until it is far advanced.15
Smoking is now recognized as a major risk factor for periodontal disease,16 in addition to its role in heart disease, lung cancer, and other disorders. It is still uncertain whether the damage to the periodontal tissues produced by smoking is due to a topical effect of the smoke on the gingiva and/or to systemic effects, such as changes in blood flow. Smoking is also implicated in the high incidence of oral and pharyngeal cancers that are found in elderly men who are both tobacco users and alcohol abusers. All forms of smoking—cigarettes, cigars, pipes—greatly increase the risk of oral and pharyngeal cancers, compared with nonsmokers. Many patients in long-term care have neurologic conditions such as Parkinson’s disease or Alzheimer’s disease that make oral hygiene measures difficult or impossible for them to perform. Similarly, patients with severe arthritis are unable to wield a toothbrush or floss their teeth. The result is plaque accumulation and increased gingival inflammation. Sensory deficits, especially deteriorating eyesight, make oral hygiene more difficult, while both impaired vision and hearing loss make it more difficult for oral health care instructions to be understood by the patient. Medications have multiple effects, some of which (xerostomia and gingival enlargement) have been described above. In addition, taste changes caused by some drugs make food taste unpleasant,17 whereas others, such as antipsychotics, can produce movement disorders (tardive dyskinesia), which may interfere with the patient’s ability to manage food utensils or oral hygiene implements. Some patients have systemic conditions that, while they do not affect the mouth directly, complicate the management of oral health problems. An example is the patient with rheumatic heart disease or other conditions that require antibiotic premedication prior to dental treatment sessions. Behavioral challenges also complicate oral health care. Residents with dementia or other psychiatric conditions may be too frightened, uncomprehending, or combative to permit dental treatment or oral hygiene procedures. Management of the Oral Health of Patients in Long-Term Care Oral health has a low priority in many nursing homes. A survey in 1995 of more than 16,000 nursing homes in the United States revealed that 1700 offered no dental services at all; 60% had no regular dental services available, except on call or offsite; and more than 1000 did not provide any oral hygiene assistance to residents.18 All incoming residents should have an oral health examination (with dental radiographs) that includes cancer screening. It should involve a visual examination and palpation of the oral tissues for changes in color, size, form, firmness, and/or surface texture; a periodontal examination; recording of missing and carious teeth, and evaluation of existing prostheses. Functionally dependent adults should be assessed for their ability to perform oral hygiene procedures. This assessment need not be an all-or-nothing evaluation. Some residents’ difficulties may be due to partial physical and/or cognitive impairment. Thus, an individual who is unable to brush his or her teeth independently may be able to do so if someone is present to direct the procedure with such instructions as “open your toothpaste, pick up your brush, put on the toothpaste,” and so on. Patients with severe arthritis or motion disorders find toothbrushing easier if the brush has a thick handle. These are available from suppliers of implements for the disabled or may be made from a standard soft-bristled toothbrush by taping sponge rubber to the handle. Checkup examinations should be done at intervals of no more than 12 months. The management of oral health problems will depend on the patient’s sensory and motor abilities, understanding and cooperation; the training, skills, sensitivity, and motivation of the staff; and the availability of funds to pay for the care needed. Ideally, oral hygiene procedures should be taught, missing teeth replaced, carious teeth restored, and periodontal treatment performed to ensure that the patient will be able to eat comfortably. Various techniques are available to stabilize loose teeth even in the presence of severe periodontal disease. Patients with extensive root caries should be given a fluoride rinse to reduce the likelihood of further decay. For patients with severely dry mouths, artificial saliva is available. Patients whose impairments prevent their performance of oral hygiene should have it performed by an aide. It should involve the use of a soft toothbrush with or without toothpaste to clean all of the teeth, particularly at the gum line on both the inner and outer surfaces of the teeth. A Swedish study published in 1997 found that nursing personnel considered oral care assistance more disagreeable than most other nursing activities.19 Such an attitude reduces the likelihood of careful oral hygiene by aides. A search on the World Wide Web under oral hygiene or oral hygiene video will provide sources of patient education brochures and tapes that may be helpful, but a dentist or hygienist is the best person to provide the necessary training.20,21 Finding the funds for oral health care in a long-term care environment is another major challenge. Medicare generally pays for dental needs only if they are the result of an accident, whereas Medicaid reimbursement varies from state to state and is usually minimal. An inquiry to the state Medicaid office or the state dental society might suggest ways to obtain some of the needed funds. The oral health of residents in long-term care facilities frequently suffers for a variety of reasons: functional and/or cognitive impairments that limit the ability of residents to care for themselves; a large variety of prescribed medications; and reduced access to oral health care. As the over-65 population continues to grow, institutions will house more people who are retaining more of their teeth and who will have even greater dental care needs. Now is the time to plan for the management of this population and to seek increased financial reimbursement.
Acknowledgment
References
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