Aging and Dental Health

The Federal Interagency Forum on Aging-Related Statistics projects that by the year 2030, the number of U.S. adults 65 years or older will reach 72 million, representing nearly 20% of the total U.S. population; this is an approximate doubling in number as compared to the year 2000.¹ Older adults are, therefore, a growing patient demographic for dental practices. Although around 5% of adults older than 65 years are edentulous, increased numbers of older adults are retaining their natural teeth compared with previous cohorts.² According to a 1999-2004 National Health and Nutrition Examination Survey (NHANES), approximately 18% of adults aged 65 years or older with retained natural teeth have untreated caries³ while a 2009-2012 NHANES found that 68% of these patients have periodontitis.⁴ Consideration of the overall clinical and oral health context of aging patients is important in order to provide optimum dental care.

The health status of adults older than age 65 years can be quite variable, ranging from functional independence to frail or cognitively impaired.^5-9 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).¹⁰ Most older persons have at least one chronic condition and many have multiple conditions.¹⁰ 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%).¹⁰ 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.^{11, 12}

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, 9, 13} 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).^{9, 13} These changes may have an effect on medication absorption and metabolism or an individual’s sensitivity to certain medications (See “Medication Considerations”).^{9, 14}

Physical changes associated with aging include decreased bone and muscle mass.¹³ Osteoarthritis may result in limitations in mobility.¹⁵ Visual changes may include age-related macular degeneration, presbyopia, cataracts, glaucoma, or diabetic retinopathy.^{5, 15} Patients may experience age-related hearing loss, which may affect their ability to communicate.^{5, 15} Postural reflexes can become dampened, and falls become more common in elderly individuals.^{5, 13, 14}

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, 15} Older patients with poor cognitive health will have difficulty managing medications, medical conditions, or other self-care, including dental hygiene.¹⁵ 

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 2012.¹⁶ Ninety percent of people 65 years of age and older reported using any prescription drug in the prior 30 days;¹⁶ 8 or more prescriptions are used daily by 30% of elderly individuals.¹⁷ The high prevalence of polypharmacy among older adults may lead to inappropriate drug use, medication errors, drug interactions or adverse drug reactions.^{5, 14} 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.¹⁴ 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.¹⁷ A review of older dental patients’ medical history and current medications, both prescription and OTC medications/supplements,^{18, 19} should be done regularly.^{5, 14}

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.¹⁴ The most frequently taken OTC medications by older adults include analgesics, laxatives, vitamins, and minerals.¹⁴

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.²⁰ 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.²¹

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.^{14, 22} The American Geriatrics Society has published a 2023 update to the Beers Criteria for potentially inappropriate medication use in older adults.²³ 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.²³ 

General

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, 24} 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 day^{5, 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, 25, 26} 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.²⁴ 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, 24, 26} 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.²⁷ 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.¹⁴ The authors¹⁴ 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.¹⁴

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.¹⁵ Education of the caregiver, as well as the patient, is an important part of the prevention and disease management phase of dental care.^{5, 15}

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.²⁸ Patients should be approached from the front at eye level and use of nonverbal communication, such as smiling and eye contact, is important.²⁸ 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.”²⁸

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.¹⁵

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.¹⁵ The same oral care routine should be followed consistently, as possible.¹⁵ 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.¹⁵

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.²⁸ It is important to make sure that speaking loudly and slowly does not introduce a patronizing or condescending tone of voice.²⁸ Yellowitz in The ADA Practical Guide to Patients with Medical Conditions¹⁵ advises the following in communicating with patients with hearing loss and/or hearing aids:

• In patients who read lips, face the patient while speaking, speak clearly and naturally; and make sure your lips are visible (remove mask). Be at the same level as the patient.
• Gain the patient’s attention with a light touch or signal before beginning to speak. Be sure the patient is looking at you when you are speaking and avoid technical terms. Use written instructions and facial expressions.
• Inform the patient before starting to use dental equipment or when equipment is changed, resulting in an altered experience, e.g., vibrations from a low-speed versus a high-speed handpiece.
• In patients with hearing aids, minimize background noise when speaking. Avoid sudden noises and putting your hands close to the hearing aid(s). Patients may want to adjust or turn off the hearing aid(s) during treatment.
• Written and illustrated materials and websites can be used to help explain dental information, procedures, and postoperative instructions.

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.²⁸ Help ensure the patient can clearly see demonstrations and read written materials, including appointment cards and instructions.¹⁵ The following tools and strategies¹⁵ can assist visually impaired older adults in the dental office:

• Large-print magazines in the waiting room
• Good lighting throughout the office; add spot/task lighting in areas used for completing forms
• Large print on prescription bottles
• Install blinds or shades to reduce glare
• Use contrasting colors on door handles, towel racks, and stair markers

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.¹⁵ 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.¹⁵ Floss holders or interdental cleaners/brushes can aid in cleaning between teeth.¹⁵ Increasing the frequency of dental cleanings and examinations can help promote optimal maintenance of oral hygiene.¹⁵

1. Federal Interagency Forum on Aging-Related Statistics. Older Americans 2012: Key indicators of well-being. https://agingstats.gov/docs/PastReports/2012/OA2012.pdf. Accessed August 21, 2023.
2. Public health and aging: retention of natural teeth among older adults--United States, 2002. MMWR Morb Mortal Wkly Rep 2003;52(50):1226-9
3. National Institute of Dental and Craniofacial Research. Dental caries (tooth decay) in seniors (age 65 and over). National Institutes of Health. http://www.nidcr.nih.gov/DataStatistics/FindDataByTopic/DentalCaries/DentalCariesSeniors65older.htm. Accessed August 21, 2023.
4. Eke PI, Dye BA, Wei L, et al. Update on Prevalence of Periodontitis in Adults in the United States: NHANES 2009 to 2012. J Periodontol 2015;86(5):611-22.
5. Yellowitz JA, Schneiderman MT. Elder's oral health crisis. J Evid Based Dent Pract 2014;14 Suppl:191-200.
6. Razak PA, Richard KM, Thankachan RP, et al. Geriatric oral health: a review article. J Int Oral Health 2014;6(6):110-6.
7. Preston AJ. Dental management of the elderly patient. Dent Update 2012;39(2):141-3.
8. Stein P, Aalboe J. Dental care in the frail older adult:  special considerations and recommendations. J Calif Dent Assoc 2015;43(7):363-8.
9. Thompson LA, Chen H. Physiology of Aging of Older Adults: Systemic and Oral Health Considerations-2021 Update. Clin Geriatr Med 2023;39(2):225-34.
10. Administration on Aging (AOA). A Profile of Older Americans (2014): Health and health care. U.S. Department of Health and Human Services Administration for Community Living. https://www.acl.gov/sites/default/files/Aging%20and%20Disability%20in%20America/2014-Profile.pdf. Accessed August 21, 2023.
11. World Health Organization. Ageing and health (Fact Sheet No. 404).  August 2022. https://www.who.int/en/news-room/fact-sheets/detail/ageing-and-health. Accessed August 21, 2023.
12. World Health Organization. World report on ageing and health.  September 2015. http://apps.who.int/iris/bitstream/10665/186463/1/9789240694811_eng.pdf?ua=1. Accessed August 21, 2023.
13. Dodds C. Physiology of ageing. Anaesthesia & Intensive Care Medicine;7(12):456-58.
14. Ouanounou A, Haas DA. Pharmacotherapy for the elderly dental patient. J Can Dent Assoc 2015;80:f18.
15. Yellowitz JA. Geriatric health and functional issues. In: Patton LL, Glick M, editors. The ADA Practical Guide to Patients with Medical Conditions. 2nd ed. Hoboken, NJ: John Wiley & Sons, Inc.; 2016. p. 405-22.
16. Kantor ED, Rehm CD, Haas JS, Chan AT, Giovannucci EL. Trends in prescription drug use among adults in the United States from 1999-2012. JAMA 2015;314(17):1818-31.
17. Sherman JJ, Davis L, Daniels K. Addressing the Polypharmacy Conundrum. US Pharm. 2017; 42(6):HS14-20. https://www.uspharmacist.com/article/addressing-the-polypharmacy-conundrum. Accessed August 21, 2023.
18. Fitzgerald J, Epstein JB, Donaldson M, et al. Outpatient medication use and implications for dental care: guidance for contemporary dental practice. J Can Dent Assoc 2015;81:f10.
19. Radler DR. Dietary supplements: clinical implications for dentistry. J Am Dent Assoc 2008;139(4):451-5.
20. Sreebny LM, Schwartz SS. A reference guide to drugs and dry mouth--2nd edition. Gerodontology 1997;14(1):33-47.
21. Tan ECK, Lexomboon D, Sandborgh-Englund G, Haasum Y, Johnell K. Medications That Cause Dry Mouth As an Adverse Effect in Older People: A Systematic Review and Metaanalysis. J Am Geriatr Soc 2018;66(1):76-84.
22. Bowie MW, Slattum PW. Pharmacodynamics in older adults: a review. Am J Geriatr Pharmacother 2007;5(3):263-303.
23. American Geriatrics Society 2023 updated AGS Beers Criteria® for potentially inappropriate medication use in older adults. J Am Geriatr Soc 2023;71(7):2052-81.
24. Jablonski RY, Barber MW. Restorative dentistry for the older patient cohort. Br Dent J 2015;218(6):337-42.
25. U.S. Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health; 2000.
26. Gregory D, Hyde S. Root caries in older adults. J Calif Dent Assoc 2015;43(8):439-45.
27. Hendre AD, Taylor GW, Chavez EM, Hyde S. A systematic review of silver diamine fluoride: Effectiveness and application in older adults. Gerodontology 2017;34(4):411-19.
28. Stein PS, Aalboe JA, Savage MW, Scott AM. Strategies for communicating with older dental patients. J Am Dent Assoc 2014;145(2):159-64.

Professional Resources

Search JADA for articles related to elderly or geriatric patients

ADA Library Services

Patient Resources

JADA “For the Patient” pages:

What are dentists seeing in older adults? (September 2022)

The changing oral health care needs of older adults (June 2020)

MouthHealthy: Life Stages: Dental health concerns in adults over 60

• American Geriatrics Society Beers Criteria: Drugs to be avoided or used with caution in the older adult
• Centers for Disease Control and Prevention: Older Adult Oral Health
• Gerontological Society of America resources related to oral care for older adults (Geron.org/OralHealth) and publication, "What's Hot: Oral Health: An Essential Element of Healthy Aging"
• Online continuing education: Geriatric Dentistry (offered by Crest and Oral-B)