TEETH should be for life. However, the hard truth is oral diseases, including tooth decay and gum diseases affect about 3.9 billion people worldwide, including the elderly.
As we age, tissues in our oral cavity go through a physiological transformation to accommodate multiple changes to the oral environment and its altered function. Teeth may go through wear from many years of chewing on different textures and hardness levels of a variety of food, the cumulative result of abrasive tooth brushing methods and exposure to corrosive food and eating habits.
Tooth wear also promotes sensitivity of teeth as there is exposure of microtubules on worn down tooth structure which triggers stimulation of nerve endings within them.
Stains from food, beverages and tobacco smoking stick to teeth surfaces and incorporate with dental plaque (the sticky colourless substance on tooth surface from activity of germs/bacteria in the mouth) to create an unpleasing sight and stubborn deposits that are difficult to remove by tooth brushing alone.
Tooth decay is also common and contributed by many factors including poor oral hygiene because of inefficiency in cleaning teeth due to altered dexterity, difficult access to all surfaces of teeth due to spaces from missing teeth, crowding of teeth and displacement of teeth from the normal alignment, and reduced salivation to buffer the acidity of plaque and “self-cleanse” tooth surfaces.
Common changes to the dentition with age:
- Teeth worn down either on the chewing surfaces or facial surfaces
- Hypersensitive teeth
- Stained teeth
- Teeth decay and more prominently on root surfaces
- Dry mouth
Gums are more vulnerable to bacterial infection from the plaque and might become inflamed, where it will swell up, bleed easily and may cause a persistent dull ache either localised or or generally involving the whole jaw.
Most people are not aware of gum inflammation (also called gingivitis) because the changes are not easily identified and it is often not painful. Hence, it is referred to as the “silent disease of the gums”.
The severity of gingivitis worsens when there is more plaque and if the plaque has been there a long time. If it is not removed efficiently, plaque causes the accumulation of toxins which is harmful to the gums.
Fast facts on gum disease:
- Generally, more than 90% of the world’s population has some degree of severity of gum disease.
- In the 2010 National Oral Health Survey (NOHSA 2010) about 94% of Malaysian adults have gum disease with:
– gum bleeding (4.1%)
– calculus or tartar (41.4%)
– shallow pockets (30.3%)
– deep pockets (18.2%)
- Severe periodontitis (gum infection) is listed as the No. 6 most prevalent disease affecting 6-20% adults around the world.
- In the elderly, most cases are related to poor oral hygiene.
The earlier you detect gum disease, the better it is. Carers can look out for these signs and symptoms in the elderly they are taking care of:
- Red, swollen gums
- Gums bleed during brushing
- Gums bleed spontaneously
- Dull gum ache
- Loose teeth
- Teeth look longer than usual
- Food stuck in between teeth
- Teeth that drift/move
- Extra space between teeth
- Pus discharge
- Smelly breath
- Bad taste in mouth
- Inefficient chewing
In some susceptible individuals (take the self-assessment test at http://service.previser.com/aap/default.aspx), gingivitis may turn into periodontitis, which is a more advanced stage of gum disease affecting more underlying tooth-supporting tissues including the bone.
The bone too will undergo changes as a result of having plaque, which inevitably causes destruction of the bone and leads to teeth being unsupported, uncomfortable when chewed on and shaky.
Mobile teeth can also move beyond their original position leading to crowding of teeth and spacing between teeth. In more serious cases of bone loss, teeth are no longer stable nor able to function in the mouth and eventually require extraction.
Inflamed or swollen gums will shrink back to normal after an infection has subsided and health has been re-established through treatment, but unsupported by the destroyed and reduced bone, gum can recede further.
This will result in teeth appearing longer than before as the root surfaces are exposed. Additionally, plaque can adhere and retain on root surfaces and are often missed when brushed, leading to carious lesions on root surfaces.
Another consequence of the disease activity is the creation of spaces where gums are detached from the root surface of the tooth (this is referred clinically as gum pockets). This space will act as a reservoir for germs to dwell in and cause more infection and accumulation of toxic substances including pus.
Due to these pockets, access for cleaning can be difficult. Infection within the pocket may persist. Food can easily get stuck in between teeth and combined with an existing infection can produce halitosis (bad breath) because of the bacteria.
Dry mouth is also a common condition in the elderly, and this can increase the risk of tooth decay as well as gum disease.
Ask your dentist for teeth and gum screening on your next visit and discuss with them how to optimise your oral hygiene. Ask for a referral to a periodontal specialist if you are diagnosed with an advance case of gum disease. The specialists will provide more comprehensive care for your gums and teeth.
Both tooth decay and gum disease are treatable. Prevention and treatment of diseases are equally important for healthy oral health throughout your life. Patients may also have to change their brushing technique (ask your dentist for advice on brushing techniques and the appropriate toothbrush design for your needs) to ensure good access to difficult areas, particularly around loose or displaced teeth as well as to clean well between teeth and in shallow pockets.
There are specially-designed brushes that can be used to go in between narrow to wide spaces between teeth. They are called interdental brushes that come in different diameters and look like tiny bottle brushes.
Dentists recommend the use of fluoridated toothpaste as it is beneficial for the prevention of tooth decay and gum disease.
While using a mouthwash is advised, instructions should be adhered to when using an antiseptic mouthwash. When there is an acute infection of the mouth, an antiseptic mouthwash should be used with brushing (never to be used alone!). It should be used for a maximum of two weeks as some rinses contain ingredients that can stain the teeth and oral tissues when used over a longer period. Ask your dentist when in doubt.
You should wait at least 15-20 minutes after using fluoridated toothpaste before using th antiseptic mouthwash, then gargle for at least one minute before spitting out.
Stop using the rinse immediately and seek medical assistance if there are any side effects (such as ulcers, sharp / burning sensation) as there might be an allergic reaction to some ingredients.
Regular and periodic visits to the dentist is highly recommended for the elderly, particularly if there are co-existing medical conditions such as diabetes mellitus, high-blood pressure / hypertension, cardiovascular disease, chronic respiratory diseases and anything that requires the intake of certain medications which may alter the health of the gums and oral tissues.
If you are a smoker, stop smoking! Tobacco smoking has been proven to be one of the most important environmental risk factors for gum disease. Those who smoke more and for a longer period of time are at a higher risk than light smokers.
Studies also show that smokers with gum disease response poorer to treatment than non-smokers and former smokers.
Key points for lifelong good oral health:
- effective oral hygiene – accessing all surfaces of teeth
- quality of brushing is more important than quantity (how best you clean your teeth rather than how many times you clean in a day)
- healthy gums do not bleed
- early detection of diseases will help prolong life of teeth
- avoid / reduce / stop hazardous habits – tobacco smoking, high sugar intake, overweight or obesity
- regular dental visits for dental and gum check – at least once in six months
Dr Shahida Mohd Said is a senior lecturer and consultant in periodontology at the Faculty of Dentistry, Universiti Kebangsaan Malaysia.
- Marcenes, W et al, 2013. Global Burden of Oral Conditions in 1990-2010: A systematic analysis. J Dent Res, 92, (7) 592
- Kassebaum, E. et al, 2014. Global Burden of Severe Periodontitis in 1990-2010: A systematic review and Meta-regression. JDR 93 (11): 1045
- Petersen, P., & Ogawa, H. 2012. The Global Burden of Periodontal Disease: Towards Integration with Chronic Disease Prevention and Control. Periodontology 2000, 60, 15–39.
- Mohd-Dom et al, 2013. Periodontal Status and Provision of Periodontal Services in Malaysia: Trends and Way Forward. Malaysian Journal of Public Health Medicine, 13(2): 38-47
Also recommended references:
- Sihatgusi. Malaysian Health Education Learning Portal on periodontal health: http://sihatgusi.info/
- Oral Health Division, Ministry of Health Malaysia: http://ohdmoh.blogspot.com/
- American Academy of Peridoontology: http://www.perio.org/patient-resources
- British Society of Periodontology: http://www.bsperio.org.uk/patients/