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The health status of adults older than age 65 years can be quite variable, ranging from functional independence to frail or cognitively impaired.5-8 According to the U.S. Administration on Aging, over 40% of noninstitutionalized adults aged 65 years or older assessed their health as excellent or very good (compared to 55% for persons aged 45 to 64 years).9 Most older persons have at least one chronic condition and many have multiple conditions.9 In the time period up to and including 2013, the most frequently occurring conditions among older persons were: hypertension (71%), arthritis (49%), heart disease (31%), any cancer (25%), and diabetes (21%).9 A 2015 report by the World Health Organization listed conditions common to older age, including hearing loss, cataracts and refractive errors, back and neck pain and osteoarthritis, chronic obstructive pulmonary disease, diabetes, depression, and dementia.10, 11

Physiologic changes that are age related include changes to cellular homeostasis, including regulation of body temperature and blood and extracellular fluid volumes; decreases in organ mass; and decline in or loss of body system functional reserves.5, 12 Changes to the gastrointestinal system include decreases in intestinal blood flow and gastric motility and increased gastric pH. Renal, cardiovascular, respiratory, central nervous, and/or immune systems may show decreased function (e.g., decreases in glomerular filtration, cardiac output, lung capacity, sympathetic response, cell-mediated immunity).12 These changes may have an effect on medication absorption and metabolism or an individual’s sensitivity to certain medications (See “Medication Considerations”).13

Physical changes associated with aging include decreased bone and muscle mass.12 Osteoarthritis may result in limitations in mobility.14 Visual changes may include age-related macular degeneration, presbyopia, cataracts, glaucoma, or diabetic retinopathy.5, 14 Patients may experience age-related hearing loss, which may affect their ability to communicate.5, 14 Postural reflexes can become dampened, and falls become more common in elderly individuals.5, 12, 13

Older adults may also demonstrate a spectrum of cognitive acuity, ranging from not at all affected to mild cognitive impairment to frank dementia.5 Dementia is a syndrome characterized by progressive deterioration in multiple cognitive domains, severe enough to interfere with daily functioning.5, 14 Older patients with poor cognitive health will have difficulty managing medications, medical conditions, or other self-care, including dental hygiene.14

According to data from NHANES, 39% of people aged 65 years and older reported using 5 or more prescription drugs (“polypharmacy”) in the prior 30 days during the year 2011 through 2012.15 Ninety percent of people 65 years of age and older reported using any prescription drug in the prior 30 days;15 8 or more prescriptions are used daily by 30% of elderly individuals.16 The high prevalence of polypharmacy among older adults may lead to inappropriate drug use, medication errors, drug interactions or adverse drug reactions.5, 13 The average older adult takes 4 or 5 prescription drugs; in addition, these individuals may also be taking 2 or 3 over-the-counter (OTC) medications.13 The problem may be compounded by use of multiple healthcare providers and pharmacies, as well as by multiple, stepwise medication additions in the management of individual chronic diseases such as type 2 diabetes and hypertension.16 A review of older dental patients’ medical history and current medications, both prescription and OTC medications/supplements,17, 18 should be done regularly.5, 13

Drugs most commonly prescribed in elderly patients include “statin” drugs for hypercholesterolemia; antihypertensive agents; analgesics; drugs for endocrine dysfunction, including thyroid and diabetes medications; antiplatelet agents or anticoagulants; drugs for respiratory conditions; antidepressants; antibiotics; and drugs for gastroesophageal reflux disease and acid reflux.13 The most frequently taken OTC medications by older adults include analgesics, laxatives, vitamins, and minerals.13

Medication-related mechanisms implicated in xerostomia and salivary gland dysfunction in older adults include anticholinergic/sympathomimetic effects, topical effects of inhaled medications, dehydration (e.g., from diuretics), salivary glands vasoconstriction, and changes in salivary composition.19 A 2017 systematic review and meta-analysis found that urologic medications used to manage urinary frequency and incontinence, antidepressants, and psycholeptics (including antipsychotics, anxiolytics, and hypnotics) were significantly associated with xerostomia in older adults.20

Older adults frequently show an exaggerated response to central nervous system drugs, partly resulting from an age-related decline in central nervous system function and partly resulting from increased sensitivity to certain benzodiazepines, general anesthetics, and opioids.13, 21 The American Geriatrics Society has published a 2019 update to the Beers Criteria for potentially inappropriate medication use in older adults.22 Beers Criteria potentially inappropriate medications have been found to be associated with poor health outcomes, including confusion, falls, and mortality. For example, opioid-containing medications should be avoided in older individuals with a history of falls or fractures.22

Xerostomia affects 30% of patients older than 65 years and up to 40% of patients older than 80 years; this is primarily an adverse effect of medication(s), although it can also result from comorbid conditions such as diabetes, Alzheimer’s disease, or Parkinson’s disease.5, 8, 23 Xerostomia, while common among older patients, is more likely to occur in those with an intake of more than 4 daily prescription medications.5 Dry mouth can lead to mucositis, caries, cracked lips, and fissured tongue.8 Recommendations for individuals with dry mouth include drinking or at least sipping regular water throughout the day5, 8 and limiting alcoholic beverages and beverages high in sugar or caffeine, such as juices, sodas, teas or coffee (especially sweetened).8 

Older adults are at increased risk for root caries because of both increased gingival recession that exposes root surfaces and increased use of medications that produce xerostomia; approximately 50% of persons aged older than 75 years of age have root caries affecting at least one tooth.2, 24, 25 Ten percent of patients 75 to 84 years of age are affected by secondary coronal caries; this is likely related to the prevalence of restorations in the older population.23 Adoption of good oral hygiene, which includes use of rotating/oscillating toothbrushes, and the use of topical fluoride (i.e., daily mouth rinses, high fluoride toothpaste and regular fluoride varnish application), as well as attention to dietary intake have been recommended in the literature.8, 23, 25 A 2017 systematic review evaluated the effectiveness of silver diamine fluoride (SDF) in the management of caries in older adults, finding 3 randomized, controlled trials conducted in Hong Kong addressing the effectiveness of SDF on root caries and none addressing coronal caries.26 The three clinical trials supported the use of SDF for prevention and arrest of root caries in older adults; although there were no serious adverse events reported, SDF does cause dark staining of the treated lesions and has to be reapplied for continued efficacy.

Because cardiovascular disease is common among older individuals, it has been suggested by Ouanounou and Haas that the dose of epinephrine contained in anesthetics should be limited to a maximum of 0.04 mg.13 The authors13 recommend that even without a history of overt cardiovascular disease, the use of epinephrine in older adult patients should be minimized because of the expected effect of aging on the heart. They recommend monitoring blood pressure and heart rate when considering multiple administrations of epinephrine-containing local anesthetic in the older adult population.13

Cognitive limitations affecting dental care and home oral care

Patients with severe cognitive impairment, including dementia, are at increased risk for caries, periodontal disease, and oral infection because of decreased ability to engage in home oral care.14 Education of the caregiver, as well as the patient, is an important part of the prevention and disease management phase of dental care.5, 14

Communication during the dental appointment may be challenging when the older adult has cognitive impairments. It is recommended that the number of people, distractions, and noise in the operatory be minimized when providing care to a patient with dementia, although a trusted caregiver in the room may provide reassurance to the patient.27 Patients should be approached from the front at eye level and use of nonverbal communication, such as smiling and eye contact, is important.27 The dentist should begin the conversation by introducing himself or herself. Because a patient with cognitive limitations may become overwhelmed by information easily, instructions should be simple and sentences short, such as, “Please open your mouth.”27

Because cognitive impairment or dementia can affect a patient’s ability to follow instructions following oral surgery, it is recommended that practitioners ensure local hemostasis (i.e., sutures, local hemostatics, socket preservation techniques) prior to dismissal from the dental practice.14

Dentate patients with cognitive limitations should be encouraged to brush their teeth two or more times daily; use of an electric or battery-operated toothbrush should be considered.14 The same oral care routine should be followed consistently, as possible.14 In patients with removable prosthetic devices, the device(s) should be removed, inspected, and cleaned before bed and returned to the mouth in the morning.14

Physical and sensory limitations affecting dental care and Home oral care

Patients with hearing loss:  Dental care providers should speak slowly, clearly, and loudly when talking with older patients to enhance hearing and understanding. 27 It is important to make sure that speaking loudly and slowly does not introduce a patronizing or condescending tone of voice.27 Yellowitz in The ADA Practical Guide to Patients with Medical Conditions14 advises the following in communicating with patients with hearing loss and/or hearing aids:

Patients with visual loss:  Age-related visual impairment, such as cataracts, glaucoma or presbyopia, can diminish a person’s ability to process nonverbal conversational cues that frequently are communicated visually.27 Help ensure the patient can clearly see demonstrations and read written materials, including appointment cards and instructions.14 The following tools and strategies14 can assist visually impaired older adults in the dental office:

Patients with physical limitations/loss of mobility:  Osteoarthritis or rheumatoid arthritis in the hand, fingers, elbow, shoulder, and/or neck can affect a person’s ability to maintain good quality home oral care.14 Modification of manual toothbrush handles (e.g., with Velcro® straps or attaching a bicycle handlebar grip) or use of an electronic toothbrush with a wide, grippable handle can help accommodate for lost mobility.14 Floss holders or interdental cleaners/brushes can aid in cleaning between teeth.14 Increasing the frequency of dental cleanings and examinations can help promote optimal maintenance of oral hygiene.14

Oral Health Care for the Elderly (Trans.2020:XXX)

Resolved, that the American Dental Association supports the development of policy at the federal, state, and local levels that supports the fair, equitable, choice driven provision of dental care to promote improved health and well-being in elderly patients.

Department of Scientific Information, Evidence Synthesis & Translation Research, ADA Science & Research Institute, LLC.

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