Oral Health-related Issues with Institutionalized Older Adults

A certain proportion of seniors will end up in a nursing home (NH) facility for a variety of reasons, however primarily, for their inability to no longer care for themselves. The greatest causes of disability have been listed as visual impairment, dementia, hearing loss and osteoarthritis. However, a large portion of these individuals will have dementia. Current worldwide rates of dementia for those aged 85+ are 25-30%. In Canada and the US, rates of dementia for NH residents are 57-65% and 70%, respectively.19,20

Although seniors in general are living longer and baby boomers in particular appear to be healthier, the demand for nursing home admissions will increase in the future, but the age of entry will be older. The latest available US statistics demonstrating this increase in NH admissions reported a change from age 81.1 years in 1985 to 82.6 years in 1997.16 Predictions are that these figures will continue to rise as the boomers reach older age and most likely, these figures have already increased.

Oral care in a nursing home is problematic and has been reported by numerous authors to be actually “deplorable.”17,18 There seems to be not only a fear but a direct aversion to the provision of oral care by most caregiver staff. Despite nursing home legislation mandating that residents receive oral care, there does not appear to be a system to monitor the implementation of that care. Numerous reports in both the US and Canadian literature, describe horrendous breaches in the delivery of oral care including lack of toothbrushes and other oral hygiene supplies; unsanitary storage of these supplies including partial and full dentures, as well as the lack of adherence to infection control procedures in the provision of oral care.17 This situation must change as now, more than ever before, these residents are entering with most of their own natural teeth along with very expensive dental work that will rapidly deteriorate if not cared for. Typically most nursing home facilities do not have dental clinics on-site nor dental professionals to care for them. In some States in the US and in several Canadian provinces, dental hygienists can contract with families to provide preventive and therapeutic dental hygiene services, however, for a fee. Once again, this does not solve the problem of those who cannot afford care.

The primary oral challenge with nursing home residents is xerostomia, a common occurrence with this population as a result of multiple medications or what has now been coined “polypharmacy.” Jablonski reports drug prescriptions to average eight medications per resident in US nursing homes.20 These drugs typically range from psychiatric drugs such as: anti-anxiety agents; antidepressants; antipsychotics (i.e., Benzodiazepams; Tricyclic antidepressants; Lithium); to antihypertensive drugs (i.e., Beta-blockers; calcium channel blockers, ACE inhibitors) and Urinary Incontinance Drugs (i.e., Darifenacin; fesoterodine and oxybutynin).

Those with xerostomia experience oral discomfort both in eating and during the provision of oral care and therefore may be less tolerable of oral interventions. Common oral symptoms of xerostomia include: mouth odor, commissure sores, speech difficulty, swallowing and chewing difficulty, burning tongue, sleep interruption due to thirst, taste disorders and prosthesis irritation. These conditions can result in increased prevalence of periodontal disease, which has been reported to be higher in this population group. Additionally, increases in denture-related lesions such as denture stomatitis as well as higher prevalence of oral cancer, are common.

The most common result of prolonged xerostomia is the prevalence of root caries, which can cause significant pain, as well as the inability to enjoy eating many foods. These caries are difficult to treat and deteriorate quickly if not addressed in the early stages and often result in tooth loss. Broken down teeth and missing teeth affect one’s inability to chew food properly, thus placing the person at risk for malnutrition.

The inability to chew food effectively has a negative impact on the overall health of the individual. The American Dietetic Association’s recent position paper indicated that nutrition is the major determinant of successful aging.21 Adequate nutrition is an effective disease management strategy that reduces chronic disease risk, slows disease progression and reduces disease symptoms. Thus the effects of poor oral health for this population sector can have long ranging negative effects for the institutionalized senior. Diminished psychological well-being, diminished overall life satisfaction, and social isolation due to broken teeth and breath malodor can all have a negative impact on self-esteem as well as ultimate longevity.

The situation in nursing homes both nationally and internationally must be addressed, particularly as the Baby Boomers begin to enter these institutions. To date, a suitable solution has not been found.