The proportion of elderly people worldwide is increasing rapidly. Malaysia, as one of the developing countries, is also experiencing a rapid growth in the aged population. Due to the demographic transition, more older people are at risk of age-related chronic diseases, including compromised oral health. Poor oral conditions may lead to functional limitation (trouble biting and chewing food), psychological impacts (uncomfortable eating in front of others), pain and discomfort (discomfort when eating) and behavioral impacts (limit kinds or amount of foods).

Despite the improvement of oral health status across all age groups worldwide, the oral health of older people is far from optimal. Dental caries, periodontal disease, partial and total tooth loss, xerostomia, and oral precancer or cancer lesions are prevalent in this group. In addition, the negative impacts of oral ill health as measured by socio-dental indicators like problems with eating, chewing, smiling, and speech, as well as pain and discomfort, are greater in the older population compared to the younger age group.

Common oral diseases & conditions among older people:

1. Dental caries (Dental decay)

   Dental caries have been shown to be a major public health problem in older people. A high prevalence rate of dental caries is found among the old age population in both developed and developing countries worldwide as the disease affects almost 100 percent of the population. Malaysia shares similar caries experiences whereby the older age group has a higher prevalence of dental decay, missing due to caries, and filled teeth compared to the younger age group. Data from the recent National Oral Health Survey of Adults showed that the prevalence of dental caries among the elderly aged 60 years and above was 99.9%, and about three-quarters of the decayed teeth needed to be extracted.

2. Periodontal disease (Gum disease)

   Dental calculus and swollen gums are among the manifestations of periodontal disease, and are commonly seen in the older adult population. In Malaysia, the proportion of elderly people who have healthy gingiva was only 1.9%. Similar to dental caries, the determinants of periodontal disease are closely linked to social and behavioral factors. The accumulation of dental plaque due to poor oral hygiene, low education and economic status, the presence of systemic diseases and regular smoking have effects on the progression of periodontal diseases in older adults.

3. Tooth loss

   In Malaysia, a trend of an increasing proportion of edentulism (total tooth loss) as age increases was observed. About 1.3 percent of the 35-44 years of age group, 35.5 percent of age between 65-74 years old and 54.2 percent of 75 years and above of were reported to be edentulous. The major reasons for tooth loss were severe dental caries and periodontal disease. However, factors that lead to tooth loss are not always dentally related. Other factors that were reported to have an association with edentulism include socio-economic status, lifestyles, systemic diseases that enhance periodontal disease, dental attitude, affordability of dental treatment, and damaging habits like tobacco, drugs, and alcohol.

4. Xerostomia (Dry mouth)

   Xerostomia, or dry mouth, is also a common complaint among older people. Older adults who suffer from chronic dryness of the mouth are likely to experience severe difficulties in chewing, eating and communicating. Drug-induced xerostomia is most common in old age because vast proportions of older adults take at least one medication that can cause salivary dysfunction, like those used for hypertension, psychiatric problems, Parkinson's disease, and urinary problems. In denture-wearing patients, reduced salivary secretion may lead to poor adaptation of dentures, as well as an increased risk of dental caries and periodontal disease.

Dental considerations for the medically compromised elderly

Many older adults suffer from multiple chronic illnesses like hypertension, diabetes mellitus, coronary heart disease, and stroke. Coupled with the medicines taken, chronic diseases can affect the oral health of older adults. As we know, poor oral health may lead to restricted food choices due to chewing disability, as well as problems with communication and self-esteem.

Some oral complications in older adults with chronic diseases include:

• Dry mouth (xerostomia) - This condition is an abnormal dryness of the mouth due to decreased secretion of saliva. It can also increase the pathogenic bacteria in the oral cavity, predisposing to bad breath (halitosis), dental caries, gum disease, and oral mucosal lesions. Some hypertensive and cardiovascular disease medications may cause dry mouth.
• Gum or periodontal disease - Poor oral hygiene combined with dry mouth can lead to inflammatory gum disease caused by bacteria in dental plaque. Plus, enlargement of the gums is one of the side effects of some medicines used to treat hypertension.
• Dental caries - One of the roles of saliva is to balance the pH of the oral cavity through its buffering effect of carbonates and phosphates. Reduced salivary flow due to the medications taken may increase the risk of developing dental caries among older adults with chronic diseases.
• Oral mucosal lesions - Several hypertensive, diabetes mellitus, and cardiovascular disease medications can cause mucosal lesions like lichenoid reactions. Frequent dental visits are recommended.
• Fungal infections - Inadequate dental plaque control plus reduced salivary flow can also lead to fungal infection in the oral cavity.
• Burning mouth & taste changes - Some cardiovascular disease medications have side effects like burning of the mouth and taste changes.

Oral health recommendations:

1. Increased salivary flow
   • Drink water frequently so that the mouth is always moist.
   • Chew sugar-free chewing gum to stimulate the salivary glands to produce saliva.
   • Eating fibrous foods.
   • Avoid drinks containing alcohol and caffeine.
   • Avoid using commercial mouthrinses that contain alcohol or peroxide, which can further dry the mouth.
2. Remove dental plaque efficiently
   • Brush your teeth at least twice a day, preferably after every meal. Choose a proper toothbrush, e.g., small head, soft bristles, finger grip handle.
   • Clean the interdental spaces by using floss or an interdental brush.
3. Increase fluoride intake
   • Use fluoride toothpaste to prevent tooth decay.
   • An alcohol-free fluoride rinse is also recommended after toothbrushing to help remineralize enamel.
   • Professionally-applied topical fluoride gel is also required for older adults with a high risk of developing dental caries.
4. Diet control
   • Avoid eating too much sugary food and drinks to prevent dental caries.
5. Professional care
   • Visit the dentist frequently for oral examinations and preventive procedures. The dentist can also emphasize and educate good oral hygiene practices for maintenance of oral health.
   • Short dental appointments are also recommended for older adults with medical problems.

Special considerations:

• Older adults suffering from stroke are very susceptible to oral diseases due to impaired manual dexterity. Inadequate dental care combined with side effects of drugs like dry mouth may lead to fungal infection, dental caries, gum disease, and eventually tooth loss. An electric toothbrush or a modified handle of a toothbrush is recommended for tooth cleaning.
• Similarly, older adults with osteoarthritis are also recommended to use an electric toothbrush and long-handled floss to facilitate oral hygiene care.
• For diabetes patients, it is important to have good oral hygiene habits for the prevention of periodontal diseases. Severe periodontal disease will affect diabetes control.