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 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, 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