Hygiene and Prevention: Thinking Beyond Children

Randy F. Huffines, DDS (RH): Dentists often have varying opinions, but when I worked on the American Dental Association's Elder Care Task Force, one of the few things all of the members agreed on was that unique prevention was the main area where the profession should focus with regard to the aging population. The primary reason is that, unlike in the past when an overwhelming majority of elderly patients were edentulous, presently, only about 25% of US seniors are edentulous. The vast majority of seniors who visit a general practice have some teeth, so prevention is extremely important.

One of the main causes of tooth loss as we age is caries, which is probably even more of a factor than periodontal disease. However, most of the research that has been conducted on caries prevention has centered on children. It has not focused much on prevention in adults, especially older adults. A May 2010 Journal of the American Dental Association(JADA) article surveyed 467 general dentists in general practice-based research networks and found that respondents were much less likely to provide adult patients with in-office caries preventive agents than children.

Nearly all seniors have some gingival recession, and the resulting exposed root surfaces are much more susceptible to decay than surfaces that are covered with enamel. We also encounter problems with saliva in older patients, primarily related to medication use. Saliva is crucial in preventing tooth decay, so when its function is compromised, problems ensue.

ID: How are dentists responding to these needs, and how should they be responding?

RH: We have known about the caries rate for seniors for a few decades now, but the profession has been slow to respond. The first step is recognizing that this is a huge part of the practice; there are 46 million seniors in the United States, and during the practice life of dentists graduating from school right now, that number will surpass 80 million.

The profession must become more educated about the prevention needs of older adults. Older adults still experience enamel caries, but their main issue is with root caries, which is something that dentists do not deal with in children.

ID: What are some of the most popular and impactful solutions being utilized in this realm?

RH: I have been using glass-ionomer cements for decades, but they are often used incorrectly in the United States. Dentists are very familiar with composites, but these are completely different products and should not be used like composites. It is important to be careful, follow directions, and use the proper techniques when working with glass-ionomer cements.

Just as it is in children, fluoride is extremely important in older patients—especially those who have dry mouth. Nothing can replace the natural saliva, but fluoride is still the best alternative. Many high-risk patients need to be on prescription fluorides (ie, 5,000 parts-per-million), which are either brushed on or used in trays. New products that have become available should be used adjunctively rather than in place of fluoride.

Many of these adjunctive products have important uses, however. Silver diamine fluoride has only been available in the United States for a couple of years. It has been used primarily for children and has been extremely effective. Dentists are still finding new ways to use it. For example, in an Alzheimer's patient for whom no ideal restorative options exist, the application of SDF could buy some time in maintaining his or her teeth. Silver diamine fluoride is an alternative that we will continue to find additional uses for as we learn more about it.

Fluoride varnishes are also important for caries prevention among aging adults. They are the only in-office products that we use in my practice. They provide as much benefit for adults as they do for children. The industry has been seeing more and more calcium phosphate products as well; however, those are primarily useful as an adjunct for particular patients.

One myth that is bolstered by TV commercials involves the use of solutions sometimes erroneously called “artificial saliva” or “salivary substitutes.” Although they can make a patient's mouth feel better, they really have no therapeutic benefit in regard to caries or periodontal disease. Saliva has hundreds of compounds that impart different benefits to oral health, whereas saliva substitutes really only address making the mouth feel moist and slick. They do not affect caries. I prescribe them frequently, but only to make patients more comfortable, not to therapeutically treat anything.

It may seem obvious, but identifying and providing education on the best ways for older patients to clean their teeth is something we really need to consider. Older patients tend to have recession, missing teeth, tilted teeth, and heavily restored teeth. All of these factors make their teeth harder to clean than a younger person's teeth, especially if the patient also has trouble with manual dexterity, problems with their eyesight, or other issues related to aging. Some older patients may have dramatically altered their diet if a spouse encountered health problems and can no longer cook. Others may have cut out soda but increased their consumption of sports drinks because advertisements have led them to overlook the fact that sports drinks can be just as acidic and sugary as soda.

In addition, removing plaque becomes less simple in these older patients. The hygienist, dentist, and assistant really need to consider the needs of each individual patient rather than plugging everyone into a cookie-cutter approach.

ID: What developments in hygiene and prevention for older patients do you expect to see in the near or long-term future?

RH: Continuing to learn about and become more comfortable with the challenges posed by these older patients will be the most important thing.

For example, as we age, our pulp shrinks and our tubules become more calcified. Because this process makes our teeth less and less sensitive over time, a caries lesion can grow very large before an older patient feels the symptoms. They will not have the sensitivity and early warning signs that a 35- or 40-year-old will have. Elderly patients with recession and medications that make their mouths dry must be more frequently examined; otherwise, their carious lesions could potentially become huge and maybe even unrestorable by the time that they call the office to report sensitivity. Therefore, patients in their 80s or 90s may need to be on a more frequent recall to apply fluoride varnishes every 3 months instead of every 6 months. Again, it is just a matter of learning to assess the needs of each individual patient.

Another issue is the reporting of xerostomia (dry mouth). A JADA study in March 2010 found a poor correlation between xerostomia and hyposalivation. Xerostomia, or the feeling of oral dryness, is a symptom, whereas hyposalivation is a sign, identified through a measurement of the amount of saliva that finds it inadequate. Many of the participants stated that their mouth was dry despite having an adequate amount of saliva. Others had inadequate amounts of saliva but did not report having dry mouth. Therefore, in practice, simply asking the patient about dry mouth is not always sufficient. Unfortunately, we have limited tests in the office to measure the quality of saliva, which is surprising because many dentists describe it as “the bloodstream of the mouth.” In the future, dentistry needs to evaluate this because poor salivary function is the driving force for caries in many of our older patients. Periodontal disease is an important issue as well, and one for which a significant amount of misinformation exists in the profession. That topic is worthy of an entire separate article.

Randy F. Huffines, DDS
Private Practice
Johnson City, Tennessee
Past President and Fellow
American Society for Geriatric Dentistry