Loss and no replacement or inadequate replacement of missing teeth causes major nutritional difficulties. Smoking has been identified as a major risk factor for periodontitis, in addition to increasing susceptibility to oral cancer.  The multiple medications taken by many long-term care patients are often the cause of xerostomia (dry mouth), and some cause gingival enlargement.  Many of the effects of oral disease may be prevented or treated by appropriate measures when a long-term care facility provides the resources and staff training.

Periodontitis (Gum Disease)

Periodontitis is a chronic inflammatory disease of the gingiva and supporting tissues.  If untreated, it results in the progressive loss of bone support around the teeth, the opening of a separation (“pocket”) between gum and tooth, and increasing tooth mobility.  One obvious effect of advanced periodontal disease is on nutrition. Patients with many loose teeth or missing teeth are often unable to chew any but the softest foods.  They have a tendency to swallow mouthfuls of poorly chewed food rather than endure uncomfortable chewing. Such inadequate mastication may result in choking and sometimes in digestive problems.

Other effects of periodontitis have become apparent.  Evidence is accumulating that the presence of periodontal infections increases susceptibility to pneumonia and other lung conditions, cardiovascular disease, and stroke.

Another long-recognized effect of periodontitis is its role in the presence of diabetes.  Glucose levels in patients with type 1 or 2 diabetes with active, advanced periodontal disease are more difficult to manage than in patients without periodontal disease. Conversely, when the diabetic state is uncontrolled, the patient is more susceptible to periodontal abscesses and rapid periodontal breakdown.

Many oral conditions adversely affect a resident’s nutrition and general health status, and the mouth, in turn, reflects many systemic problems.  Advanced periodontitis— fairly common in the elderly— reduces the ability to chew, exacerbates problems in the control of types 1 and 2 diabetes, and has been found to be a risk factor in pneumonia, cardiovascular disorders, and stroke.

Loss and no replacement or inadequate replacement of missing teeth causes major nutritional difficulties.  Smoking has been identified as a major risk factor for periodontitis, in addition to increasing susceptibility to oral cancer. 

Tooth Loss and Problems with Non-Replacement

The non-replacement of missing teeth is one of the principal causes of inability to chew.  Many older people, especially those with low incomes, fail to have lost teeth replaced for financial reasons. If many teeth are missing, chewing becomes more and more difficult, and malnutrition is likely to result.  A related problem is the continued use of dentures that no longer fit properly.  The patient either leaves the dentures out of the mouth or uses them only intermittently.  Even when a partial denture fits well, the patient is at higher risk for root caries unless the denture is removed daily, and both the denture and teeth are cleaned thoroughly.

Dental Caries (Cavities)

Caries is generally thought of as a disease of young people because the highest incidence of new-enamel decay occurs during the first three decades of life in the enamel on the chewing surfaces and the proximal surfaces (the surface at which each tooth contacts its neighbor).  However, older adults are susceptible to root caries, a condition in which decay invades the exposed roots of teeth and may result in pain, tooth fracture, abscess formation, and pulp death, requiring root canal treatment or extraction.

Salivary Changes

There has been a longstanding consensus in the health care community that patients in the over-65 age group have a diminished salivary flow.   This has recently been questioned, and it now appears that much of the “dry mouth” problem is related to multiple medications taken by the people in this age group. Medications include antihypertensive, psychotropics, antihistamines, antiarrhymics, and many others.

Oral (Mucocutaneous) Conditions  

There are a number of ulcerative, desquamative conditions that cause the oral tissues to be painful and make eating a highly unpleasant experience. They include candidiasis (thrush), erosive lichen planus, herpes zoster (shingles), and mucous membrane ulcerations resulting from chemotherapy.

Incidence of Oral Cancer (Neoplasms)

Approximately one-half of the 30,000 cases of oral cancer reported each year are found in patients over 65 years of age. Many deaths from this disease could be averted by early detection during routine screenings.

Systemic Conditions That Affect the Mouth

Smoking is now recognized as a major risk factor for periodontal disease, in addition to its role in heart disease, lung cancer, and other disorders.  Many patients in long-term care have neurologic conditions such as Parkinson’s disease or Alzheimer’s disease that make oral hygiene measures difficult or impossible for them to perform.  Similarly, patients with severe arthritis are unable to wield a toothbrush or floss their teeth.  The result is plaque accumulation and increased gingival inflammation.  Some patients have systemic conditions that, while they do not affect the mouth directly, complicate the management of oral health problems.  An example is the patient with rheumatic heart disease or other conditions that require antibiotic premedication prior to dental treatment sessions.