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Oral health and seniors  

How's them choppers?

Let's do a bit of time traveling. Cast your mind back to the days when your grandparents were the age you are now. Chances are at least one of them wore dentures, or needed to. And way back then, you probablyTake care of your teeth thought that's what happened when people got older, and at some point it would eventually happen to you. 

Fortunately, that's one possibility that doesn't have to come true. The fact is teeth can last a lifetime, as long as they're properly maintained. Along with consistent brushing and flossing, the process involves a healthy diet, access to fluoride-related preventative agents (like fluoridated water, toothpaste, rinses or gels) and regular visits to your dentist.

The more compromised your mouth is through missing teeth, gum disease or tooth decay, the more important it is that you see your dentist. Dental science has changed dramatically since granddad's day. Back then, it was frequently a matter of "fill or pull." Happily, dentists have seen their practices shift from filling decaying teeth to a focus on prevention -- keeping the mouth healthy and the teeth intact.

"In days of yore, dentists were focused on teeth to the exclusion of (almost) everything else," says Dr. Victor Sterling, author of Fill in the Gaps: A Practical Guide to Healthy Teeth (Addison-Wesley). "Before fluoridation came into effect, there was such a tremendous amount of decay they really didn't have time for anything else. They were kept busy from morning to night just filling teeth. 

Now, with fluoridation and the dramatic reduction in the number of decayed teeth, dentists are focusing on gum disease, and as a result, fewer people are losing teeth due to gum disease and fewer are having full dentures." Dentists of course, can't take full credit for the improvement. It's up to each patient to "attack the plaque" by faithfully undertaking two simple low-tech procedures: brushing and flossing.

Plaque

Plaque, the nasty scum that coats teeth and collects in the crevice between tooth and gum, is a mixture of bacteria, food particles and protein molecules in saliva. The bacteria, especially Streptococcus mutans, feast on dietary carbohydrates -- sugars and starches -- and excrete acid that etches cavities in teeth. 

Left unattended for 24 hours, plaque begins to harden, eventually forming a stone-like covering called calculus, commonly referred to as tartar. (It's this hard coating dental hygienists scrape from your teeth.) 

Tartar, with its microscopic fissures and crannies, contributes to the attack on teeth and gums by providing a hideout for yet more bacteria and plaque, adding even more of the destructive acid to the environment surrounding teeth and also irritating gums.

Attacking plaque

  • Brush at least twice a day, suggests Sterling: Right after breakfast to clear your mouth of plaque formed overnight as well as the morning's toast; then before going to bed.
  • Use a soft- or medium-bristled brush directed at a 45-degree angle and concentrate on one or two teeth at a time. Place the bristles inside the cuff of the gum where it joins the tooth -- without forcing -- and then gently brush back and forth, rolling up and out to dislodge the plaque from the cuff.
  • Use a low-abrasive fluoride toothpaste that won't wear teeth down. (Look for the seal of approval from the Canadian or American dental associations.)
  • Scrub too vigorously with a hard toothbrush and you'll eventually wear a groove in the tooth enamel, leaving teeth sensitive and vulnerable to decay.
  • A toothbrush can reach three of the tooth's five surfaces but it can't scrub plaque from between teeth. That's why you need to floss.
  • Choose the floss (waxed, unwaxed, flavoured or not) with which you feel most comfortable. Slip it between two teeth down to just under the gumline, then slide it up one tooth and then repeat on the other tooth. Plaque is soft, so you don't have to do this energetically.
  • If it's too hard to get your fingers in there, use a floss holder, available in drug stores or even your local supermarket.
  • Encourage healthy gums with a gum massage using the rubber tip found on some toothbrushes or under a water irrigator.

The fluoride factor

People who've managed to reach adulthood without dental caries (tooth decay) owe a debt to a turn-of-the-century Colorado dentist who noticed many of his patients whose teeth were mottled had few cavities. The mottling indicated a high fluoride intake (fluorosis), consistent with the relatively high amount of fluoride occurring naturally in the area's water. 

By the 1930s, scientists had determined a level of one part per million would not cause mottling, but would protect teeth from demineralization. Many communities, backed by the American Dental Association and the American Medical Association, then began starting to introduce fluoride to local drinking water sources.

When the small amount of fluoride normally present in tooth enamel is bolstered through water fluoridation, fluoride toothpastes, mouth rinses or fluoride treatments, the enamel -- already the hardest substance in the body -- becomes even tougher and more resistant to decay. This preventative action is especially beneficial when children receive the treatment in their first eight years of life.

Before widespread fluoridation, studies indicated three distinct danger periods for tooth decay: around age seven, when the crowns of baby teeth were threatened; age 14, when the permanent teeth were under attack and later, between 30 and 40 when cavities began to appear with an ongoing frequency.

Fluoride's efficacy doesn't diminish as the mouth ages; in fact, it may be more critical to adult teeth than was once believed. It's thought that fluoride use and the presence of calcium and phosphorus in saliva can reverse some degree of demineralization of coronal tooth enamel.

Fluoride also helps prevent root caries -- cavities that bedevil older folk when the gum tissue that normally covers the roots recedes or when incorrect brushing wears a groove in the tooth enamel at the gumline, leaving roots vulnerable. Because they're not protected by enamel but are covered with a softer layer called cementum, exposed roots are more susceptible to decay than are the enamel-covered crowns. 

The dreaded root canal

These cavities present a challenge to the dentist: firstly, they have to be detected and then accessed for treatment. If decay progresses too far into the cementum, reaching the nerve canal of the root, excruciating pain ensues.

Although the term strikes fear in the hearts of many, a root canal offers blessed relief from the pain of an infected tooth. After freezing the tooth and creating a small opening in the top (or tongue side, if the aching tooth is in the front), the dentist carefully removes all of the soft tissue from each of the tooth's roots. 

The now-hollow tooth (and each root) is packed with a special material and the opening is filled. Unfortunately, the tooth can be vulnerable to fracture and should be strengthened by a crown or other restorative procedure.

Adults, especially those who grew up in a pre-fluoride era, often have several old fillings whose interface with tooth enamel can fail, allowing bacteria to establish a foothold of decay. These, along with root cavities and periodontal disease (gum disease) present serious dental challenges to older people. Part of the problem lies in the aging process.

"As people get older, there's some normal change in the tissues in the mouth," says Linda Jamieson, coordinator of the dental hygiene program at Georgian College in Orillia, Ont. "More importantly, there tends to be a big change in their medical conditions, in the number of drugs they're on, lifestyle changes -- even economic changes." Losing dental benefits on retirement discourages some from continuing the regular dental checkups they'd maintained during their working lives, she points out.

Sadly, dental health really can deteriorate as people become infirm or have difficulty with mental alertness. Daily oral hygiene then rests with others -- home care workers or long-term care providers who may not be adequately trained to clean teeth properly or who are too overburdened with work to do a careful job. And a good job is vital if cavities and gum disease are to be kept at bay.

Beyond the obvious cosmetic appeal of natural teeth and the resulting effect on self-image and self-esteem, good oral health is an important factor in preserving good general health. For this reason, older people, whose health may be less stable -- or their caregivers -- need to be especially conscious of good oral care.

It's a growing dilemma. Schmitt, who is also a specialist in geriatric dentistry, notes that during her involvement with the Metro Toronto Homes for the Aged, "a very interesting phenomenon was taking place in the population coming into the homes. 

There was a significant change -- more and more were keeping their natural teeth." But having someone else clean your teeth can be humiliating and handling the situation sensitively is a challenge for caregivers. "It's not an easy thing to do because there is a privacy and self-esteem issue," says Schmitt.

She stresses the importance of dental care for people with Alzheimer's Disease as well, noting that "the best time to treat is right now, because it's only going to get worse."

Special consideration for seniors

Xerostomia, or dry mouth, is an uncomfortable condition that plagues older people, Linda Jamieson points out. Although it can be the result of a disease process that affects salivary glands, it's often a side effect of medications used to control hypertension, depression, Parkinson's Disease or other disorders. The problem is often compounded when patients are taking multiple medications or undergoing radiation or chemotherapy for cancer of the head or neck.

Dry mouth increases the risk of cavities and gum disease, says Jamieson, noting "there are antibodies -- immunoglobulins in the saliva that target some of the bacteria.

"There's also less natural cleansing, so we get bacteria and food debris accumulating around the teeth that otherwise might have been washed away."

If the situation is extreme and the patient ultimately has to have dentures, the dry mouth will result in the dentures causing rubbing and discomfort. Oral lubricants or synthetic saliva can help, but not cure the situation.

People who've managed to reach adulthood without dental caries (tooth decay) owe a debt to a turn-of-the-century Colorado dentist who noticed many of his patients whose teeth were mottled had few cavities. The mottling indicated a high fluoride intake (fluorosis), consistent with the relatively high amount of fluoride occurring naturally in the area's water. 

By the 1930s, scientists had determined a level of one part per million would not cause mottling, but would protect teeth from demineralization. Many communities, backed by the American Dental Association and the American Medical Association, then began starting to introduce fluoride to local drinking water sources.

When the small amount of fluoride normally present in tooth enamel is bolstered through water fluoridation, fluoride toothpastes, mouth rinses or fluoride treatments, the enamel -- already the hardest substance in the body -- becomes even tougher and more resistant to decay. This preventative action is especially beneficial when children receive the treatment in their first eight years of life.

Before widespread fluoridation, studies indicated three distinct danger periods for tooth decay: around age seven, when the crowns of baby teeth were threatened; age 14, when the permanent teeth were under attack and later, between 30 and 40 when cavities began to appear with an ongoing frequency.

She used to think it was just the oral bacteria," says Jamieson, "now the top three risk factors for periodontal disease are diabetes, tobacco use and the bacteria. And we're starting to feel that in the segment of the population that has a very fast progressing gum disease, those other factors are more significant than the bacteria."

Gingivitis

Early periodontal disease, known as gingivitis, is indicated by puffy, red gums that bleed easily. This is the point at which action should be taken to stop the process in its tracks before it reaches an even more destructive stage. All too often though, people assume they've brushed or flossed too hard and they try to be more gentle or stop flossing, with the result that the disease does go on to the next stage.

Periodontal disease launches a sneak attack. It's not painful, but unless discovered during a dental exam, the damage it causes may be irreparable.

Gum tissue forms a cuff around the neck of each tooth (a cuff that should be cleaned by proper brushing and flossing). As periodontal disease progresses, this tissue is gradually destroyed, deepening the cuff around affected teeth. (Your dentist, using a probe, measures the amount of gum recession during your checkup.) 

As this pocket deepens, it becomes impossible to clean by normal oral hygiene techniques and becomes a haven for bacteria. A resulting inflammatory response destroys the microscopic strands of protein that hold the tooth anchored to the bone -- and damages bone as well. Without early intervention, the tooth will be left without support and will have to be extracted.

But periodontal disease does more than threaten teeth. A number of studies point to a strong relationship between periodontal disease and cardiovascular disease (CVD), myocardial infarction (MI) and even stroke. It's thought that oral bacteria released into the bloodstream from the inflamed pockets in the gums encourage platelets (particles in the blood that are part of the blood clotting mechanism) to clump, forming thrombi or clots. Gum infections also trigger an inflammatory response that also promotes clotting and vascular complications that lead to CVD and MI. People with CVD also appear to be at risk when oral bacteria migrate to, and damage, heart valves.

Keep your dentist informed

It's important to keep your dentist informed of your medical history, including the drugs you're taking. Are you taking an aspirin every day? Blood thinners? Does your dentist know of your history of heart, circulatory or other serious disease?

Drugs, including those used to treat hypertension, can interact, perhaps dangerously, with some local anesthetics.

Even if you've lost the battle to keep your teeth and consequently wear full dentures, you still need to see a dentist regularly. As gums and bone change, those dentures will fit less snugly and may require a relining for a comfortable fit. (Improperly fitting dentures can cause constant friction on tissues in the mouth that can lead to pre-cancerous growths.) 

This visit gives your dentist an opportunity to examine the state of your mouth, noting unusual bone loss (possibly a consequence of osteoporosis), the presence of tumors or even indicators of diabetes.

Other changes and their effects

The mouth is a dynamic environment. When a tooth is lost, its neighbors will shift, causing changes in a person's bite, perhaps enough to create malfunction in the hinge of the jaw, the temporomandibular joint. Opposing teeth, left without resistance, tend to grow longer than normal. Loss of a tooth though, leads to bone loss. It also can affect self-image and provoke loss of self-esteem.

Teeth, of course, are chiefly used for biting and chewing the food needed to maintain a vigorous body. But when those teeth are sensitive to hot, cold or acidic foods, people dodge discomfort by avoiding the offending chow, and a once-balanced diet goes askew. 

If chewing is less efficient -- the result of broken or missing teeth -- food is swallowed in chunks. When it's not sufficiently ground up, there's less surface area available to acids and enzymes in the digestive tract, and fewer nutrients are absorbed.

Forces exerted during chewing or grinding change when teeth are removed and facial muscles or jaw joints (temporomandibular joints or TMJ) can become strained and painful. TMJ syndrome frequently results in migraine headaches or restricts the mouth from opening fully.

Verbal communication is another important function of the mouth and teeth. With everything in the oral cavity intact and functioning normally, speech is easily interpreted. Unfortunately, missing teeth can interfere with normal speech formation, resulting in embarrassment and misunderstanding. (It's a problem frequently faced by people who are in the process of adjusting to new dentures.)

 

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