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More oral health care needed for ageing populations

Theresa Braine

Mexico City

Berta Diaz has a wide grin. What she lacks is a toothy smile. Like most elderly adults worldwide, she has lost most of her teeth.

"When they were bad, they just got pulled," said the 70-year-old patient after getting her new prostheses fitted in Dr Hugo Zamora's dental practice in Mexico City.

Diaz is one of the 60–70% of Mexicans aged over 65 with few or no teeth. Although the poor are more vulnerable to this and other problems, the oral health problems of the elderly cross class lines. Low awareness, lack of access to oral health services and the misconception that older people will not benefit from health education and preventive measures such as fluoridation, conspire to deprive the elderly of crucial care.

Oral disease is the fourth most expensive ailment to treat in most industrialized countries, according to WHO's World oral health report 2003. "Unless we take action today, many countries will not be able to pay for treatment programmes," said Dr Poul Erik Petersen, head of WHO's Oral Health Programme, with regard to the oral health needs of the elderly.

The burden of oral disease is likely to grow in many developing countries because of unhealthy diets rich in sugars and high consumption of tobacco, Petersen said. Industrialized countries spend 5–10% of their national public health resources on dental care a year, but most developing countries allocate no budget at all to the control of oral disease.

"In many developing countries, the only treatment is tooth extraction in case of pain and problems with teeth," said Petersen. "Millions of older people ... will suffer tooth loss. Eventually they will be without natural teeth."

As with other health issues, older people have very different oral health needs to children and younger adults. They are more likely to take medication that causes dry mouth, leading to tooth decay and infections of the mouth. More than 400 commonly used medications – many of them for chronic conditions to which the elderly are susceptible – can dry out the mouth.

Oral cancer is another danger that can strike after years of over-consumption of tobacco and alcohol. The incidence of this cancer is rising in places with growing or high tobacco use, Petersen said, calling the burden of oral cancer a "major challenge to many countries".

Mexico's situation is typical of that worldwide. Dr Ernesto Acuña, who specializes in geriatric dentistry in Mexico City, agreed that it is common to yank a tooth that aches or is loose. People start losing teeth as early as their 40s, he told the Bulletin.

The main causes of tooth loss – gum disease and untreated cavities – are rampant in Mexico. Acuña believes that 90% of the Mexican population has untreated cavities, and Mexico's health ministry says that the country's six million people over age 65 have on average 18 missing or damaged teeth out of 32.

In many cases, ill-fitting dentures can reduce a person's quality of life, for example by impeding their ability to chew. This is what happened to Diaz. Diagnosed with diabetes 15 years ago, she eventually got gum disease, a common result. Today she has no natural teeth on top and only four below.

In Mexico, as in the rest of the world, the lower a person's socioeconomic status the more likely that no preventive measures will be taken. An unfounded belief by families and health-care practitioners that tooth loss is inevitable during ageing, lack of education on the importance of oral health and components of dental care, poor access to services and a low dentist-to-population ratio complete the picture.

Even in developed countries such as the United States older people face a host of impediments to continuing dental care even if they used to go to the dentist regularly, said Dr Barbara Gooch, an oral health expert from the US Centers for Disease Control and Prevention (CDC). After retirement they may be unable to afford dental care. If they become less mobile, they may not be able to get to the dentist.

The results of oral health problems reverberate throughout the body. Nutritional problems are the immediate result of problems with chewing, which can start long before tooth loss. "I was chewing badly and I got stomach problems," Diaz said.

"The mouth is the gateway to the digestive system," Acuña said, adding that caregivers tend to think that if an older person is eating, then he or she is fine.

But chewing difficulty makes people shun foods that they can't swallow easily, and those are often ones with fibre and essential nutrients, such as fruit and vegetables. Sometimes people gravitate toward softer, processed foods which are often laden with sugar. On the flipside, some people stop eating enough and lose weight.

"The point in public health is that if oral health promotion and disease prevention are integrated with noncommunicable and chronic disease prevention, we can make progress for better oral health and prevention of oral diseases worldwide," Petersen said.

Even farther under the health-systems radar are the psychological problems associated with having discoloured, diseased or missing teeth. The person becomes uncomfortable socializing, loses self-esteem and begins a spiral of decline.

The good news is that much of the damage is preventable.

"Some people tend to think that if you're old, there is little chance that you will change your lifestyle in terms of tooth cleaning or dietary habits to be healthy, or other behaviour modifications," Petersen said. "But the experiences gained in some countries have shown that you can also at old age achieve healthy lifestyles and have positive outcomes as an effect of health-education intervention programmes."

Starting people on dental care programmes and exposing them to flouridated water and toothpaste improves dental health regardless of a person's age. Increasing the ratio of dentists to population, especially in poorer areas, is essential, as is educating caregivers such as workers in homes for the elderly. Alerting general medical practitioners on what to look for is also necessary.

In the United States in the 1950s – as was the case with most industrialized countries – more than half of the people aged 65 and over had lost all their teeth, the CDC's Gooch said. Now it is less than 30%. In addition to educating health professionals, CDC emphasizes the role patients can play in maintaining and monitoring their own oral health.