Aging With a Smile

By staff October 1, 2002

Over the course of his 85 years, Sarasota resident Elmer Tilden has seen a lot of changes in dentistry. He remembers a time when dentist's offices were cold, bare and bland and dental seats felt like two-by-fours that rose up and down.

As he contemplates today's plush adjustable chairs and needles as narrow as a human hair, he's thrilled that the age when "they used a horse syringe" to administer novocaine is long past. "There's just no comparison between dental care today and what it was 50, 60 and 70 years ago," he says.

Back then, early tooth loss made dental care a low priority for seniors. Today, though, Tilden is among the industry's fastest-growing demographic, according to a recent analysis by the American Dental Association (ADA). The association reports that over the past 20 years, adults aged 65 and over have shown a greater increase in visits to the dentist than all other age groups. Only children six and under, says the ADA, see the dentist as often.

Why the increase? The ADA attributes it to the growing number of seniors who are retaining their natural teeth. But keeping teeth longer is just half the equation. Today's seniors face challenges specific to their generation, and a host of circumstances are contributing to their surging population in dentist offices these days.

The first is tooth decay, something the National Institute on Aging (NIA) says can occur as long as natural teeth are in the mouth. And if you're over the age of 35, you're probably no stranger to decay. Chalk it up to bad timing, says Dr. Christine Koval, a reconstructive and cosmetic dentist in Sarasota. Koval says that people under the age of 35 have very few cavities because they've enjoyed the benefits of a fluoridated water system. Koval, who estimates that half her clientele consists of seniors, explains that although fluoride use is widespread today, it is most effective against tooth decay if absorbed into the tooth enamel before we reach adulthood.

Without the benefits of fluoride, most older adults have spent their lives chewing with a mouth full of large metal fillings, thanks to older drills that destroyed much of the surrounding tooth.

Plus, when you were young, cavities most often occurred in the center of your teeth. As you age, those cavities head north and south, toward the gum line. That's because the corrosive metal fillings that you got when you were 16 will eventually wear down and begin to crack. Bacteria can find its way into those cracks and lead to more cavities.

Once you get past the cavities, you have to deal with receding gums. This is a normal part of aging, but Koval says people often ignore their gums until they recede so far that they expose root surface. "Root surface has no enamel," says Koval; and since enamel is what protects our nerves from sensitivity to hot and cold, its absence means that bite of icy dessert can feel like you're chewing on aluminum foil.

This is where fluoride can still help. Koval says applying fluoride to exposed roots can de-sensitize them. "It doesn't build enamel," she says, "but it does build strength."

In addition to tooth decay and gum disease, many older patients are plagued by something called dry mouth, when the salivary glands no longer work properly. Until recently, dry mouth was considered another part of the aging process, but the NIA maintains that healthy older adults produce just as much saliva as younger adults. Saliva output is sabotaged by a number of diseases as well as medical treatments like chemotherapy or radiation therapy (which can also lead to painful mouth sores, tooth decay and cracked, peeling lips). Sarasota dentist Dr. Patti Sabers says seniors sometimes become dependent on a number of medications that deplete saliva production, and the NIA claims this is a common side effect of more than 400 common medicines used to treat high blood pressure, depression and allergies.

Dry mouth prevents saliva from washing away the acids produced by plaque, and that encourages decay and infections. Further, says Dr. Gerald Chioffi, a dentist in Orange Park, Florida, "Saliva is a lubricant. It's full of antibodies and immunoglobulins" that provide protection against viral infection. "Without saliva," he says, "bacteria can thrive."

But perhaps the biggest challenge seniors face today is the disturbing lack of basic dental services for nursing home residents, says Chioffi, who is a spokesperson for the Florida Dental Association and a dental consultant for several nursing homes in his area. "Before the era of managed care, many assisted living facilities had small offices where dentists or their workers could come in," he says. "Today, Medicare has virtually no dental health care benefits, and Medicaid has very limited resources." Without subsidized funding, many homes now find it impossible to maintain an in-house program.

Chioffi says the only seniors who are receiving regular dental attention are those who can reach a dental office under their own power or get transported there by someone else. "For patients in assisted living facilities, it's not as critical an issue, because most of these patients are still ambulatory," he says. "But in nursing homes, many patients are tube fed." He says the Alzheimer's population is the most difficult group to work with. "Because of their cognitive impairment, they cannot learn good dental care," and they are often unwilling to cooperate with dental practitioners. Chioffi regrets that so many of the nursing home patients he sees are emergency care cases. "We're basically putting out the fires rather than providing good, preventative dental care."

Sabers adds that bad oral health can lead to a host of gastrointestinal and viral ailments as well (see the report on pneumonia that accompanies this story). She points out that bacteria buildup under your tongue has a one-way ticket to your vascular system. If you don't carry it to your digestive system by swallowing it, you can absorb it into your bloodstream. Germs in the mouth and throat can spark an infection in the lungs.

Clearly, then, good dental health is important for all seniors, and there are steps you can take to ensure your own oral health for years to come.

o To relieve dry mouth, drink plenty of water and avoid sugar, caffeine, tobacco and alcohol. Before starting any cancer treatment, take care of necessary dental work, since chemotherapy and radiation can exacerbate the problem.

o Pay attention to that bite. Koval says all those years of chewing on our natural teeth can sometimes lead to a painful condition called temporomandibular joint disease, or TMJ. Sabers calls this process simple "wear and tear." She compares our mouths to a machine that, over time, simply starts to run down. Reconstructive dentistry can often correct bite problems that are the result of aging.

o Make sure you're getting some kind of fluoride. The NIA maintains that adding fluoride to the water supply is the best and least expensive way to prevent tooth decay; but in Florida, many prefer bottled water. Sabers says your dentist can recommend a fluoride toothpaste or rinse, and she knows of at least one company that has begun adding fluoride to its bottled water.

o To avoid oral cancer, cut back on the alcohol and eliminate tobacco products. If you notice any red or white patches on your gums or tongue, or sores that don't heal within two weeks, call your dentist immediately. The same goes for chewing and swallowing problems. The NIA says oral cancer occurs most often in people over 40 and often goes untreated in its earliest, most curable stage. This is especially true for people wearing dentures, since they're the group least likely to see a dentist on a regular basis.

o And speaking of dentures, the NIA says they may make your mouth less sensitive to hot foods and liquids and lower your ability to detect harmful objects. They may also require occasional adjustment because of changes in mouth tissues. Bacteria tend to collect under dentures, so clean them daily. Keep them in water or in a cleansing agent specifically designed for dentures overnight, and rinse your mouth with warm salt water every morning, before bedtime and after meals.

o Some seniors with conditions like Parkinson's and arthritis lack the manual dexterity to properly brush their own teeth. Sabers encourages these people to use electric toothbrushes. "They do all the work for you," she says, and now they come in all price ranges.

Tilden, who still uses a hand brush, says he's been blessed with "almost perpetual comfort" when it comes to dentistry but admits, "one reason is that my roots are very deep." He also maintains a rigorous schedule of visits. (Chioffi believes many seniors would benefit from three-month intervals.)

The simplest suggestion comes from Sabers, who urges, "Please, change your toothbrush! If you don't, you're just putting the same bacteria into your mouth every time you use it." She encourages her patients to toss their old brushes every four to six weeks, "if you want to stay healthy-at any age."


Researchers believe that good oral care lowers the risk of contracting pneumonia and raises the potential for surviving it.

The Centers for Disease Control (CDC) ranks pneumonia as the fifth leading cause of death in America. The most common type, streptococcus (or pneumococcus), afflicts some 500,000 people every year, and it kills 40,000 of those.

Pneumococcal pneumonia is especially devastating to the elderly. The National Institute on Aging says people in this age group are two to three times more likely to get pneumococcal infections. Twenty to 30 percent go on to develop bacteremia, an infection that occurs when pneumococcal bacteria enter the bloodstream. Of those who develop bacteremia, at least 20 percent will die.

That's a scary figure when you consider that the National Institutes of Health (NIH) says 70 percent of us are carrying pneumococcus bacteria around in our noses and throats. It spreads through coughing, sneezing and close contact, and it is a major problem in nursing homes.

The advent of managed medical care has forced many nursing homes to eliminate on-site dental care, and a group of Japanese researchers wondered if that might be contributing to the spread of pneumococcal pneumonia in those environments. They studied nearly 200 residents from 11 nursing homes in Japan and found that after two years, only 11 percent of residents who received consistent, professional dental care went on to develop pneumonia, compared to 19 percent who were responsible for cleaning their own teeth or dentures. Residents in that 19 percent were also twice as likely to die from the disease.

Why would something as simple as brushing one's teeth prevent pneumonia? "Our mouths are more bacterially laden than any other part of our body," says Sarasota dentist Christine Koval. Keeping the teeth, gums and tongue reasonably free of harmful bacteria can decrease your probability of inhaling it into your lungs where it can explode into a full-blown pneumococcal infection.

If that doesn't convince you that seniors should maintain a consistent dental health regimen, consider this: The CDC reports that outbreaks of drug-resistant pneumococcal infections are rising in nursing home populations. Up to 40 percent of the country's annual 135,000 hospitalizations for pneumonia may be caused by drug-resistant strains, and avoiding future outbreaks could be as simple as brushing your teeth.

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