Singapore Dental Journal 35 (2014) 38

Available online at www.sciencedirect.com

journal homepage: www.elsevier.com/locate/sdj

Review

An ageing population poses dental challenges

William Murray Thomsonn, Sunyoung Ma
Sir John Walsh Research Institute, School of Dentistry, The University of Otago, New Zealand

art i cle i nfo

ab st rac t
In this narrative review paper, we summarise what is known about the oral health of older

Keywords:

people, with a specic focus on the most common oral conditions in that age group. After

Older people

that, the implications for older people's oral care are considered, along with ways of

Ageing

developing and maintaining a gerodontologically capable and responsive workforce and

Dental care

oral care delivery system.

& 2014 Published by Elsevier B.V.

Contents
The oral health of older people . . . . . . . . . . . . . . . . . . . . . . . . . .
What do these data mean for the oral care of older people? . . .
Shaping a gerodontologically capable and responsive workforce
Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

The oral health of older people

A feature of industrialised societies over the last century or so
has been their steady ageing. Falling birth rates have combined with increases in longevity, with the result that older
people make up an increasing proportion of the population
[1]. The most striking example of this phenomenon is Japan,
where people aged 65 currently make up 23% of the
population and are expected to reach 38% by 2050 [2]. Similar
trends are evident (but not be as marked) in other developed
countries. In North America, the equivalent estimates are
13% and 22%; in Europe, they are 16% and 27%; and in China,
they are 8% and 23%. In New Zealand, where those estimates
are 14% and 25%, people aged 80 or more currently comprise

Corresponding author.
E-mail address: murray.thomson@otago.ac.nz (W.M. Thomson).

http://dx.doi.org/10.1016/j.sdj.2014.10.001
0377-5291/& 2014 Published by Elsevier B.V.

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about 25% of those aged 65, but that will rise to 40% by 2050.
Singapore is no exception to this phenomenon, with the
median age having virtually doubled since 1970; in the same
period, the total fertility rate more than halved, and life
expectancy at birth increased by just over 16 years [3]. The
11% of the population who were aged 65 or over remains
relatively low by international standards (for example, it is
currently 14% in New Zealand and expected to rise to 25% by
2050), but it is important to consider that it has been
increasing steadily: the key trend is the same.
Alongside the inexorable increase in the proportion of older
people, a dental transition has been occurring, whereby
the proportion of that group who are edentulous has also
been steadily falling. This is likely to have been more marked

Singapore Dental Journal 35 (2014) 38

in countries where edentulism has been a widespread

sociocultural phenomenon, such as New Zealand, Australia
and Scotland [4], but there is a lack of comparative data from
other countries. Nevertheless, it can safely be assumed that
retention into old age of at least part of the natural dentition is
increasing in developed countries.
The most common oral conditions among older people
are tooth loss, dental caries, periodontitis, dry mouth
and oral precancer/cancer [5]. These all can compromise
older people's quality of life. Each of these issues is briey
discussed below.
Edentulism is the state of having lost all of the natural
teeth; it should be distinguished conceptually and practically
from the more common loss of teeth which tends to occur
incremental throughout adult life. Becoming edentulous
requires the patient and dentist to collude in the decision
to remove the remaining dentition, usually in a single operation. Edentulism comes about because of both disease-related
and societal inuences [6]. It is now far less common than
incremental tooth loss, irrespective of age. Indeed, it can be
argued that the unplanned, crisis-driven and incremental
loss of teeth as we age presents more of a problem for the
profession and the public, because the piecemeal loss of teeth
can result in the drifting of adjacent teeth and the overeruption of opposing units, thus complicating prosthodontic
rehabilitation at a later date. Reports from cohort studies of
older adults conrm the phenomenon of incremental tooth
loss in people aged 65 or older [713].
Dental caries is perhaps the major oral problem among older
people. Reports from prospective cohort studies of populationbased samples of community-dwelling older people [10,1416]
have shown that dental caries is remarkably active among
older people, with a mean increment of about 1 surface per year
[17,18]. That rate is no different from the increment observed
among adolescents and younger adults [19]. Somewhat surprisingly for most dentists, the greater contribution to that increment among older people is made by coronal caries rather than
root surface caries (respectively comprising 60% and 40% of the
increment). South Australian research by the late Dr Jane
Chalmers demonstrated that the annual dental caries increment among older people residing in nursing homes is more
than double that observed among their community-dwelling
counterparts; among those with dementia, it is more than twice
as high again [20]. These longitudinal study data lend credibility
to anecdotal reports of dentitions being ravaged relatively
quickly after admission to a nursing home.
Periodontitis is not a highly prevalent condition among
older people. A review in Periodontology 2000 summarised
knowledge of the occurrence of periodontitis in older populations at that time [21], and concluded that periodontitis is a
disease of ageing; that is, ageing is a risk factor for loss of
periodontal attachment (other factors being equal). Essentially, most older people have had some periodontitis, with
moderate levels of attachment loss. Advanced attachment
loss (affecting relatively few sites) is apparent in a small
proportion, and a substantial minority experience ongoing
attachment loss, mainly in the form of increases in gingival
recession rather than in probing depth. Research published in
the years since that authoritative review by Locker and
colleagues has not materially changed those conclusions [22].

Chronic dry mouth occurs in a substantial proportion of

older people, affecting their speaking, enjoyment and ingestion of food, and denture wearing [23,24]. About one in ve
older people suffers from dry mouth [25,26], and they are
likely to be at higher risk of dental caries, whether because of
their compromised salivary buffering or the efforts they
go to to relieve their symptoms (such as by sucking sweets).
Higher rates of dry mouth are seen in those taking medications such as antidepressants, respiratory agents, opiatecontaining analgesics, or some cardiac or antihypertensive
drugs [2729]. Whether older people taking particular medications are at greater risk of caries is not supported by the
available epidemiological evidence [16], but dry mouth is an
important oral condition among older populations because of
its effects on sufferers' quality of life.
Oral mucosal lesions are more common among older
people. The term oral precancer generally refers to leukoplakia, lichen planus and erythroplakia, conditions with
recognised potential (especially the latter) for malignant
transformation. By contrast, the term oral cancer usually
refers to oral squamous cell carcinoma [30]. Although epidemiological data on the occurrence of oral precancer and
cancer in representative samples are hard to nd, most cases
of oral cancer occur among older people, and they occur less
commonly in developed countries than less developed ones
[5]. Clinicians should always be aware of the possibility of
such lesions being present.
All of the above conditions can affect older people's oralhealth-related quality of life (OHRQoL). Given the cumulative
nature of those conditions, it might be expected that the
OHRQoL of older people is far poorer than that of younger
adults, but that is not the case. In an interesting analysis
of Australian national oral health survey data, Slade and
Sanders [31] recently pointed out the paradox of apparently
better OHRQoL among older adults, with scale scores being
lowest among the oldest Australians. They stressed that it
should not be assumed that older people are necessarily
disabled by their accumulated burden of clinical oral disorders (such as tooth loss, dental caries, periodontal attachment loss and dry mouth); instead, it appears that their ageassociated stoicism, adaptability, capacity for coping and
ongoing reappraisal of what is actually important mean that
most manage reasonably well from day to day. Notwithstanding that phenomenon, however, the epidemiological
literature shows that OHRQoL tends to be poorer among
seniors who wear dentures, have higher numbers of missing
teeth or decayed teeth, have dry mouth, or have difculty in
eating because ofor alongsidethose states. In other
words, adaptation and stoicism enable most older people to
cope despite difculties in chewing.

What do these data mean for the oral care of older

people?
An increasing number of dentate older adults will place great
demands on the resources and skills of the dental workforce,
because of not only their having more teeth, active dental
caries and ongoing incremental tooth loss, but also because
they are more sophisticated in their demands on the oral

Singapore Dental Journal 35 (2014) 38

health care system. Functional dependency among older people has been reported to be a major barrier to service utilisation
[32]. The relationship between frailty and oral health is not
fully understood, but it is likely to be a two-way phenomenon.
Poor oral health can contribute to frailty (a) by leading to
chronic undernutrition (and eventually sarcopenia, or muscle
wasting), and (b) through periodontitis-associated increases in
inammatory markers creating systemic perturbations which
themselves increase the risk of frailty [33]. The seminal longitudinal work of Chalmers and colleagues [20] has highlighted
the contribution of frailty and dependency to higher dental
caries rates among older people.
In New Zealand, at least half of the older population will
end up in a residential aged-care facility at some stage, and
only a small proportion of those will return to their own homes
[34]; most will end their days in a care facility. Aged residential
care for the approximately 32,000 individuals in such care
currently costs the New Zealand taxpayer about $800 million
per year [35]. There are challenges in maintaining oral health
among (and providing care for) older people who are in care
[36]. Many agencies and professional groups are involved.
There are workforce issues (not only with the various dental
personnel but also with care facility staff), along with problems
in monitoring oral health and determining need, and with the
funding of any preventive or palliative care which may be
involved. Important complicating factors include the everincreasing proportion of dentate residents, and (in New Zealand, at least) the trend seen in recent decades for dependency
levels upon admission to have increased over time [37]. Those
entering care facilities have more teeth but are less able to take
care of themselves; their needs are more diverse. Recent
attention has been focused on developing a more systematic,
evidence-based approach to assessing and delivering care to
older dental patients, using dental care pathways which are
specic to particular levels of dependency [38]. Their use
should improve the likelihood of consistent and predictable
care because evidence-based and standardised levels of care
are provided, but it is too early to be able to evaluate their
effectiveness.
US work by Kiyak et al. [39] found that dental practitioners
held many negative stereotypes about older adults and that
they had only limited knowledge of geriatric dentistry. A
subsequent exploration of New Zealand dentists' knowledge
of older people's oral health found that it was generally
sound, but that most were not involved in providing ongoing
care to residents of nursing homes [40]. Most were unwilling
to get involved in such care because of the inconvenience of
leaving their practices to do so.

Shaping a gerodontologically capable

and responsive workforce
Meeting the oral health needs of the burgeoning older
population will require a diverse and capable dental workforce. A two-pronged approach is required, focusing on both
(a) new entrants to the profession via Dental Schools, and (b)
existing dentists. The latter will be through continuing
professional development for the majority of dentists, but
there will also be a greater need for postgraduate-level

education and training. Previous commentators have highlighted the need for geriatric dentistry to be incorporated into
both the undergraduate and postgraduate dental curricula
[5,41]. The need for a recognised dental specialty in gerodontology has also been raised recently [42], and there is merit in
such a consideration. However, considering that dentistry is
already a specialised health sciences eld with several existing sub-specialties, it could be argued that specialists in the
elds where the older population already constitutes a large
proportion of the patient pool could be trained further in
order to meet those gerodontological requirements. Prosthodontics and special needs dentistry are two such dental
specialties where older patients and people who are medically compromised are already routinely seen. The International College of Prosthodontists recently asserted that dental
geriatrics should be included as one of the major courses in
the postgraduate prosthodontic programme curriculum [43].
Conversely, it could be argued that prosthodontists might not
want to spend a lot of their clinical time dealing with
relatively low-level problems, and that there is indeed scope
(and room) for the specialist gerodontologist. The scarcity of
special needs dentistry specialists complicates the issue: they
would be ideally placed to provide care to the geriatric
population, but there are too few of them at present. There
is, of course, scope for the further deployment of dental
hygienists (or the relatively recent dual-qualied threrapisthygienists) in the sector alongside the dentists and dental
specialists.
Turning to the dental curriculum, the topics taught in
gerodontology need to be broad, ranging from ageing theories, older persons' nutrition, and the neuromuscular function of aged individuals to more dentally oriented subjects
such as the management of root surface caries and changes
to tissues in the denture space. Prior to treating older
patients, it is necessary for students to have sound knowledge about variations in biological ageing and for them to be
able to differentiate between normal ageing-associated
changes and the pathological effects of diseases [44]. Effective
clinical education programmes need to go beyond merely
minimum exposure to various older people to intensive and
stimulating clinical experiences in an environment that
provides the oversight and guidance which allow students
to develop a greater degree of comfort in treating older people
and provides the foundations for caring for those populations
in dental practice rather than always in an institutional
setting [45].
Currently, there is considerable room for improvement in
the education and training of dentists. For example, a substantial proportion of graduating dental students across the US
felt insufciently trained in treating older people and were
therefore less willing to manage those patients [46]. This
perception is also reected in dentists' general reluctance to
treat (and low interest in treating) older people residing in
long-term care facilities [40,47]. Dental professionals regard
providing such a service as a minimal nancial gain and
this lack of competence, condence and interest must be
addressed by adequate training in the area of gerodontology
so that the older population in need can be served [48].
Undergraduate education is the seedbed for conscientious
professionals [49], and it is therefore important to place

Singapore Dental Journal 35 (2014) 38

appropriate emphasis on oral health care for older patients in

the undergraduate curriculum [5053]. There is some evidence
that undergraduate clinical exposure to gerodontology results
in a higher likelihood of dentists subsequently providing
comprehensive care in nursing homes, because they are
exposed to a different group of older people during those
crucial undergraduate years [54,55]. Similarly, extramural activities involving older people contribute to the formation of
positive attitudes and a willingness to work with older patients
upon qualication [49].
The skills necessary for treating older patients can differ
according to the dependency level of the individual concerned. A proportion of the older population would have
received extensive dental treatment requiring comprehensive
and sophisticated designs. However, as the patients become
more debilitated or faced with restricted nancial circumstances, the ongoing maintenance issues need to be dealt
with in a timely and simple manner. The clinician needs to
adjust from a treat everything philosophy to treating and
restoring what is necessary for patients to function comfortably [56]. There is also the need to plan for failure, so that
the proportion of the dentition affected by the failure of a
component or unit is minimised and the patient is not
disadvantaged any more than absolutely necessary. That
failure can result from biological complicationssuch as
dental caries and periodontitisor patient-related failure,
where the individual is no longer able to sustain the meticulous self-care which is required to maintain complex restorations such as implant-supported bridges or overdentures. It is
crucial that the initial treatment provided can be modied in
the future to allow easier maintenance. For example, an
implant xed bridge should be designed in such a way that
it can be converted to either a removable implant prosthesis
(to improve oral hygiene access for patients who struggle
with their manual dexterity) or even more traditional conventional dentures for those who may develop severe
dementia or difculty in maintaining adequate self-care.
While oral implants have shown to improve quality of life
for older edentulous patients [57], they can also rapidly
become a burden to those who are unable to receive satisfactory maintenance [58].
It is important that clinicians are clinically competent and
experienced in a wide range of dental procedures, so that the
treatment can be delivered in the most effective and efcient
manner. The cost of dental treatment can be high; it can be
invasive and require multiple visits, and many older patients
may opt for easier (or indeed cheaper) options at the cost of
their longer-term oral health.
The fall in the prevalence of edentulism has led to a
gradual withdrawal from complete denture prosthodontics in
dental education. It has been pointed out that many recent
graduates in the UK are not condent or competent in
treating edentulous patients. The removable prosthodontics
curriculum has been reduced to a bare minimum [59].
As pointed out in respect of New Zealand, an ongoing
absolute fall in the number of edentulous people has led to
a de facto abandoning of complete denture prosthodontics
and its relegation to clinical dental technicians [60]. The overrepresentation of low-income adults among the edentulous
population has further hastened the dental profession's

general abandoning of that area of practice. Earlier commentators have already suggested the possibility of teaching
complete dentures through the approach of duplicating
patients' existing dentures or modifying these duplicate
dentures according to patients needs [59,61]. This could
enable simplication of the removable prosthodontic curriculum, but dentists are the ones who must diagnose, treat
and plan for any future oral health needs of our older
patients. Without an ongoing, comprehensive understanding
of removable prosthodontics, the profession's ability to meet
the ongoing needs of edentulous (or even partially dentate)
older patients would be compromised.

Conclusions
Steady increases in both the absolute and relative numbers of
older peopletogether with increases in tooth retention into
old agepose particular challenges for the oral care system.
Although the other oral conditions are important, dental
caries remains by far the greatest clinical challenge faced
by those treating older people. The dental profession will
have to be equipped to meet the dual challenges of treating
and preventing the disease in a group which is usually
hard to reach and which has not enjoyed much attention
from policy-makers to date, at least where oral health is
concerned. There is a need to identify, develop and test
innovative approaches to catering for older people's oral
health needs.

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