Cavities to Cancer: The Silent Epidemic of Oral Disease
by Joyce Baldwin
| Geriatric Times |
 |
March/April 2001 |
|
Vol. II |
|
Issue 2 |
Oral health conditions ranging from dental caries to periodontal disease and
cancer plague older adults, but there is much that non-dental health care
practitioners can do to improve the situation, according to the surgeon
general's first report on oral health care issued in May 2000.
"What amounts to a 'silent epidemic' of dental and oral diseases is
affecting some population groups," David Satcher, M.D., Ph.D., U.S. Surgeon
General, wrote in the report, noting that poor older Americans are particularly
vulnerable.
Of adults 65 to 74 years of age, 23% are diagnosed with severe periodontal
disease, and 30% of people over age 65 years are edentulous. About 30,000 cases
of oral and pharyngeal cancer are diagnosed annually, primarily in elderly
patients, and most older people take medications that make them more prone to
dry mouth, which decreases saliva flow and can be a prelude to root caries and
other oral side effects. Older adults also may have health conditions or
financial difficulties, including lack of dental insurance, that hinder them
from receiving proper oral health care.
All these factors point to the need for non-dental health care providers to
include examination of the oral-pharyngeal cavity in a patient assessment.
While internists and other health care providers examine many areas of the
human body, the oral cavity often is overlooked. "We don't look at the mouth
because we assume it's the dentist's prerogative, but it is part of the entire
person," Loreto S. Albiol, M.D., an internist with a special interest in
geriatrics and medical director of Manor Care Bethesda in Bethesda, Md., told
Geriatric Times.
For many patients, having a health care provider pay attention to the oral
cavity can be a prompt to make a dental appointment. "Older people see a
physician more than they see a dentist," Denise J. Fedele, D.M.D., M.S., a
contributing writer of the geriatric section of the surgeon general's report,
explained to GT. "Hopefully, health care providers will develop a
relationship with a dental facility where they can refer patients with oral
health problems. Non-dental health care providers get very little training in
oral health. They need to perform frequent oral exams, be more comfortable
[with them] and get familiar with what is normal or abnormal." Fedele, who is
chief of professional development and research at the Veterans' Affairs
Maryland Health Care System of Baltimore, said health care providers should be
encouraged to seek advanced continuing education in oral health care.
The craniofacial complex, which helps protect us from infection and allows
us to eat, smile and interact with others in myriad ways, is inextricably
linked with overall health, but at times receives scant attention from health
care providers.
Teresa Dolan, D.D.S., M.P.H., told GT, "Somehow in our health care
delivery system, the mouth has become disconnected from the rest of the body;
it's really an artificial disconnection." Dolan, who is associate dean for
academic affairs and director of geriatric dentistry at the University of
Florida College of Dentistry, emphasized the value of treating dental problems.
"It's less expensive, easier to treat and easier on the patient in terms of
comfort level," she said.
By adapting a National Cancer Institute (NCI) smoking cessation program,
Dolan has developed a program she calls "The Four As" that encourages health
care professionals to "Ask, Assist, Advise and Arrange" with regard to oral
health care.
The relationship of diabetic health to oral health is significant. Fedele
explained, "Research is beginning to show that diabetics, particularly poorly
controlled diabetics, can have more periodontal disease. Diabetics may also
have more candidiasis and a higher incidence of dental caries, burning mouth
syndrome and dry mouth." Conversely, Fedele said, "Advanced periodontal disease
may negatively impact the control of diabetes."
Furthermore, as the surgeon general's report stated, new research is
pointing to associations between chronic oral infections, heart and lung
diseases, and stroke. "Studies on the relationship with gum disease and
cardiovascular risk and stroke are preliminary, but are beginning to show that
there may be a relationship between untreated oral disease and general health,"
said Fedele. "Clearly, more research is needed in this area."
Older people with multiple health problems may need to be referred for
immediate dental attention. "A frail elder with 'tender teeth' should be
considered for an urgent evaluation because they don't have the reserve to not
eat for a week or two while their teeth get better," Steven Johnson, P.A.-C,
told GT. "As we grow older and more frail, we really don't have the
reserve to sustain physical or emotional challenge. If you have a seriously
infected tooth or gingivitis, you don't have two weeks to wait and make an
appointment because you can have a spiral of medical complications develop that
could be life-threatening and expensive." Johnson is a physician assistant in
the department of internal medicine at the Palo Alto Medical Foundation in Palo
Alto, Calif., and current president of the Society of PAs Caring for the
Elderly (SPACE).
From the University of California, Los Angeles, School of Dentistry and
School of Public Health came a suggestion that patients with some physical
impairment or those who lack dexterity can benefit from simple modifications
that allow them to continue good oral hygiene practices. "Stroke patients who
have lost function may not be able to do home care such as brushing [teeth],"
said Kathryn A. Atchison, D.D.S., M.P.H., who is a professor in the division of
public health and community dentistry. She explained to GT that patients
can "fabricate an extension on a toothbrush or add a new handle such as a
rubber ball or bicycle handle to compensate for a lack of function."
Atchison also pointed out that it is very difficult to get good oral health
care for older people who are institutionalized. "Caregivers in the nursing
homes are overworked, trying to deal with the general health of the residents,
and they often don't have the time or the inclination to help with daily oral
hygiene for the residents," she said. "It is very difficult for them to get
good oral health care, especially for people who are bedridden. Nursing home
medical directors need to be sure they have a dentist on call who can provide
care, give annual exams and do in-service training for the nursing staff."
Caswell A. Evans, D.D.S., M.P.H., project director and executive editor of
the surgeon general's report, said that even edentulous elderly patients can
benefit from good oral care. Evans, assistant director of the Los Angeles
County Department of Health Services, told GT, "There is a misperception
among those who have lost their teeth that because they have no teeth they have
no need for dental care. But…as the surgeon general's report on oral
health points out, oral health is about much more than just teeth. Oral and
pharyngeal cancers, infections, nutritional deficiencies, and evidence of
disease or adverse conditions elsewhere in the body, are among the factors that
can be detected as a result of an oral examination. Everyone can certainly
benefit from oral health care."