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- Herausgeber: John Wiley & Sons
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- Sprache: Englisch
Fully updated reference to clinical knowledge and strategies for effective oral healthcare in frail older adults
Taking an evidence-based approach, with theoretical and clinical knowledge underpinned by the literature, Oral Healthcare and the Frail Elder provides a comprehensive reference to management strategies for dental diseases as noncommunicable diseases in older populations. The book presents a global perspective with current guidance for clinicians, addressing the particular challenges of providing dental care for people who are confronting frailty in old age. Reflecting the numerous developments in the discipline since the previous edition was published, this Second Edition has been thoroughly updated throughout with 15 new chapters.
The first section covers background information, including demographics, social considerations, and factors affecting oral health in this population. The second half of the book is devoted to clinical management strategies.
Some of the new topics discussed in this edition of Oral Healthcare and the Frail Elder include:
- Theories and significance of oral health in frailty and oral health-related quality of life, and the influence of the life-course on oral health
- How sugar, tobacco, and alcohol initiate and sustain oral diseases, as with other noncommunicable diseases, into old age
- Mitigation of dental caries, periodontitis, gingivitis, mucositis, and other non-communicable diseases of the mouth
- Infection control, communications and tele-dentistry, mobile dental services, and strategies to appraise the usefulness of community-based oral healthcare programs
With an emphasis on population and public health in the context of non-communicable disease, the Second Edition of Oral Healthcare and the Frail Elder is an important resource for clinicians dealing with the geriatric population, including dentists, dental hygienists, dental therapists, denturists and dental technicians, nurses, and geriatricians.
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Veröffentlichungsjahr: 2025
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Table of Contents
Cover
Table of Contents
Title Page
Copyright Page
Foreword
Preface: The Challenge of Aging and Frailty and Why a Second Edition?
List of Contributors
1 Demography of Aging and Frailty, and the Epidemiology of Oral Conditions
Demography of Aging and Frailty
Epidemiology of Oral Conditions in Older People
Conclusion
References
2 Challenges with Noncommunicable Diseases and Frailty
Noncommunicable Disease
Frailty
Noncommunicable Diseases of the Mouth
Risks for Noncommunicable Diseases of the Mouth
Social Determinants
Conclusion
References
3 Theoretical Perspectives on Frailty, Oral Health‐Related Quality of Life, and Well‐Being in Old Age
Health
Oral Health
Frailty
Oral Frailty
Managing Ill‐Health and Frailty
A Clinical Scenario
Conclusion
References
4 Communities and Frail Elders
What Is a Community?
Culture and Ethnicity
Barriers to Equitable Healthcare
Equitable Healthcare and Cultural Competence
Conclusion
References
5 Oral Healthcare Policy, Equity, Economics, and Political Action for Aging Populations
Purpose of Policy
Categories of Public Health Policy
Forming Health Policy
Equality and Equity
Adopting Health Policy
Global Strategy on Oral Health
Conclusion
References
6 The Influence of the Mouth and Mouthcare on the Body‐Image and Social Interactions of Frail Elders
Body‐Image and Oral Health
Social Isolation, Loneliness, and Depression
Clinical Script
Conclusion
References
7 Ethical and Moral Considerations for Oral Healthcare of Frail Elders
Healthcare Ethics
Frailty
Ethical Theory and Principles in Healthcare
Patient‐Centered Care, Care Ethics, Narrative Ethics, and Feminism
Elder Abuse
An Ethical Framework
Clinical Context
Clinical Scripts
References
8 Educating a Workforce for Dental Geriatrics
Teaching and Learning Dental Geriatrics
Exposure to Frailty
Postgraduate Education
Cultivating Clinical Reasoning
Promoting Compassion
Healthcare‐Teams
Conclusion
References
9 Chronic Orofacial Pain and Movement Disorders in Old Age and Frailty
Assessing Pain
Age‐Related Changes in Processing Pain
Orofacial Pain
Movement Disorders and Orofacial Pain
Conclusion
References
10 Nutritional Consequences of Oral Health in Frail Elders
Changing Nutritional Needs of Frail Elders
Malnutrition/Undernutrition in Elders
Diet and Oral Health in Frail Elders
References
11 Dry Mouth and Medications
The Salivary System
The Role of Saliva
What Is Dry Mouth?
How Do We Measure Dry Mouth?
Prevalence and Impact of Dry Mouth
Medications and Dry Mouth
Managing and Preventing Dry Mouth
Conclusion
References
12 Dementia, Sleep Apnea, and Dysphagia
Dementia
Sleep and Aging
Swallowing, Dysphagia, and Pneumonia
References
13 A Framework for Assessing Oral Healthcare Programs in Residential Care Facilities
Challenges
Healthcare Accountability
Residential Facilities
Conclusion
References
14.1 Mitigating the Effects of Harmful Commodities on Dental Caries and Periodontal Diseases: Section 1: Dental Caries
Caries Through the Life‐Course
Conclusion
References
14.2 Mitigating the Effects of Harmful Commodities on Dental Caries and Periodontal Diseases: Section 2: Periodontitis and Gingivitis
Periodontitis as a Noncommunicable Disease
Periodontitis and Other Noncommunicable Diseases
Conclusion
References
15 Treatment Planning, and Integrating Oral and General Healthcare
Integrating Oral and General Health
Assessing the Need for Care
Planning Protocols
Infections
Conclusion
References
16 Care and Management of Frail and Osteoporotic Elders with Special Emphasis on Minor Oral Surgery
Minor Oral Surgery for Elders—General Considerations
The Osteoporotic Patient
Respiratory Conditions
Cardiovascular Diseases
Diabetes Mellitus
Psychological Disorders
Cancer
Recommendations and Conclusion
References
17 Oral Rehabilitation of the Frail Elder
Endodontic Rehabilitation
Restoring Endodontically Treated Teeth
Partial Tooth‐Loss
Removable Dental Prostheses
Tooth‐Supported Overdentures
Complete Tooth‐Loss
Implant‐Supported Prostheses
Dental Restorations and Prostheses
Digitally Constructed Prostheses
Cross‐Infection During Dental Treatment
Denture Hygiene
Sleep Apnea and Denture Use
Conclusion
References
18 Integrating Oral Health in Palliative Medicine
Dentistry in Palliative Care
Oral Health in Palliative Care
Therapies
Oral Health and Terminal Illness
Nausea and Vomiting
Dentistry
Conclusion
References
19 Mobile Dental Services
Preferences of Frail Elders
Service Models
Setting‐up Mobile Dental Services
Scope of Mobile Services
Cost‐Effectiveness
Challenges
Conclusion
References
20 Communications and Teledentistry
Introduction
Principles of Communication
Person‐Centered Communication
Medical and Dental Records
Teledentistry
Conclusion
References
21 Oral Healthcare for Frail Elders in Low‐Income Communities
Global Expenditures on Health
Appropriatech
Responses to Constrained Resources
Australia and New Zealand
Canadian Indigenous Communities
Hong Kong
South Africa
Thailand
Conclusion
References
22 Summary
Index
End User License Agreement
List of Tables
Preface
Table 1 Five‐year probability of survival with low or high frailty and co‐mo...
Chapter 1
Table 1.1 Theories of aging.
Chapter 7
Table 7.1 General and dental signs of elder abuse.
Chapter 8
Table 8.1 Characteristics of healthcare‐teams.
Chapter 9
Table 9.1 International Classification of Orofacial Pain.
Table 9.2 Details of pharmaceutical drugs identified throughout the text.
Chapter 10
Table 10.1 Example food‐based dietary guidelines for older people.
Table 10.2 Examples of widely used instruments to screen for malnutrition i...
Chapter 11
Table 11.1 Overview of the functions of saliva.
Table 11.2 Overview of reported associations between dry mouth and drugs.
Table 11.3 Overview of Cochrane reviews of interventions for dry mouth and ...
Table 11.4 Overview of evidence for the various therapies for dry mouth.
Chapter 14.1
Table 14.1.1 Silver fluoride used with other chemicals to mitigate dental c...
Chapter 16
Table 16.1 The American Society of Anesthesiologists Physical Status Classi...
Table 16.2 Antiresorptive drugs.
Table 16.3 Antibiotic prophylaxis for oral surgery.
a
Table 16.4 Oral anticoagulant and antiplatelet drugs.
Chapter 17
Table 17.1 Context of restorative treatments for elders who are robust or f...
Chapter 18
Table 18.1 Grading oral mucositis.
Table 18.2 Adverse effects of disinfecting acrylic resin dentures.
Table 18.3 Medications to control nausea and vomiting.
Chapter 21
Table 21.1 Appropriate treatments for tooth loss when resources are low, me...
List of Illustrations
Chapter 2
Figure 2.1 Noncommunicable diseases and associated risks.
Figure 2.2 Web of dental caries as a noncommunicable disease.
Figure 2.3 Global burden of untreated dental caries in permanent teeth. Prev...
Figure 2.4 Global burden of >6 mm loss of periodontal attachment. Prevalence...
Figure 2.5 Possible links between periodontitis and type 2 diabetes.
Figure 2.6 Global burden of severe tooth loss. Prevalence (proportion) and i...
Figure 2.7 Residual ridge resorption. Radiographs (a) and (b): elderly siste...
Chapter 3
Figure 3.1 International Classification of Function.
Figure 3.2 Significance of the mouth in old age. Bidirectional arrows illust...
Figure 3.3 Two models of oral health based on the international classificati...
Figure 3.4 Frailty as a continuum from vigor to incapacity.
Figure 3.5 Metatheory of adaptation to expectations and anxieties from loss ...
Chapter 4
Figure 4.1 Destination as percentage of 281 million migrants in 2020.
Figure 4.2 Equity versus equality.
Figure 4.3 The concept of cultural competence in healthcare.
Figure 4.4 Indicators at initial (orange) and subsequent (blue) assessments ...
Chapter 5
Figure 5.1 (a) Quality assurance framework.(b) Intervention mapping....
Figure 5.2 Strategic policies for maintaining oral health.
Figure 5.3 Primary oral healthcare pyramid for frail people.
Chapter 6
Figure 6.1 Gingival and periodontal health before removing plaque and calcul...
Figure 6.2 Gingival and periodontal health after removing plaque and calculu...
Chapter 7
Figure 7.1 Bioethical theory and moral actions.
Figure 7.2 Emergency protocol of action for managing elder abuse.
Figure 7.3 Ethical framework.
Chapter 8
Figure 8.1 A model of clinical reasoning in oral healthcare.
Chapter 10
Figure 10.1 Interrelationship between biopsychosocial factors contributing t...
Chapter 11
Figure 11.1 The salivary glands.
Figure 11.2 Salivary reflex secretion. Afferent stimuli are integrated in th...
Chapter 12
Figure 12.1 Examples of clock drawings.
Figure 12.2 (a) Global prevalence of dementia (with 95% uncertainty interval...
Figure 12.3 Writing a patient's name on a denture with indelible ink. (a) Ab...
Figure 12.4 Swallowing. (a–c) The tongue squeezes the bolus along the palate...
Figure 12.5 Nose, mouth, pharynx, and larynx.
Figure 12.6 Algorithm for approaching the differential diagnosis for dysphag...
Figure 12.7 Drooling, food debris, and visible microbial plaque in a frail m...
Chapter 13
Figure 13.1 A framework of assessment to improve quality of healthcare.
Figure 13.2 Indictors of oral healthcare in residential facilities.
Figure 13.3 Oral health care track.
Figure 13.4 Incrementally increasing standard of care for each assessment‐ti...
Chapter 14.1
Figure 14.1.1 Destruction from dental caries over three years.
Figure 14.1.2 Balancing the risk of dental caries in old age.
Figure 14.1.3 Effects of aqueous 40% silver fluoride followed by 10% stannou...
Figure 14.1.4 Gingival inflammation after 38% silver diamine fluoride (pH 13...
Chapter 14.2
Figure 14.2.1 A 74‐year‐old woman with dementia, type 2 diabetes, and neglec...
Figure 14.2.2 Management of a hypoglycemic emergency.
Figure 14.2.3 Interruption schedule for anticoagulants to reduce risk of pos...
Chapter 15
Figure 15.1 Model of oral health. (a) Domains of a framework of oral health ...
Figure 15.2 Wheelchair transfer.
Figure 15.3 Mechanical lift transfer. (a) Arrows pointing to ceiling‐mounted...
Figure 15.4 Hand‐held radiographic unit.
Figure 15.5 (a) The right side of a dental panoramic radiograph (DPR) displa...
Figure 15.6 Continuous treatment planning.
Figure 15.7 Flow and resources of treatment planning.
Chapter 16
Figure 16.1 Medication‐related osteonecrosis of the mandible. Multiple infec...
Figure 16.2 Equipment for monitoring blood pressure and oxygen saturation.
Figure 16.3 Hematoma on the right cheek one week after a soft tissue biopsy ...
Chapter 17
Figure 17.1 A periradicular lesion centered on the mesial root of a molar to...
Figure 17.2 Composite resin used to restore teeth for frail patients.
Figure 17.3 Vertical fractures in a mandibular molar and premolar of a 72‐ye...
Figure 17.4 Examples of the shortened dental arch.
Figure 17.5 Cast metal resin‐bonded fixed partial denture with a ceramic pon...
Figure 17.6 Fiber‐reinforced resin‐bonded fixed partial denture made indirec...
Figure 17.7 Maxillary incisors contoured as overdenture abutments.
Figure 17.8 Dental caries and gingivitis of maxillary overdenture abutments....
Figure 17.9 (a) Teeth preoperatively. (b–d) Teeth transitioning to overdentu...
Figure 17.10 Viscoelastic material as a functional impression for relining a...
Figure 17.11 Identity labels embedded in dentures.
Figure 17.12 (a) Mechanical attachments between dentures and oral implants i...
Chapter 18
Figure 18.1 (a) Global causes of death. (b) Global need for palliative care....
Chapter 19
Figure 19.1 A mobile dental clinic with a dental chair (Jörg und Sohn GmbH, ...
Figure 19.2 Mobile dental equipment, University of Zurich. (a) Mobile units....
Figure 19.3 Treatment for home‐bound elders.
Figure 19.4 A traveling mobile dental van, University of Malta. (a) Mobile v...
Figure 19.5 Model of portable dental services.
Chapter 20
Figure 20.1 The healthcare team.
Figure 20.2 Examples of mouthcare cards for frail residents.
Figure 20.3 Left: guide for preferred photographic images. Right: example of...
Chapter 21
Figure 21.1 Proportion of gross domestic product (GDP) attributed to healthc...
Figure 21.2 Effect of energy supply on healthcare in rural and low‐income re...
Figure 21.3 Ranked performance of healthcare systems.
Figure 21.4 Healthcare performance compared to spending in 2014 as percentag...
Guide
Cover Page
Table of Contents
Title Page
Copyright Page
Foreword
Preface: The Challenge of Aging and Frailty and Why a Second Edition?
List of Contributors
Begin Reading
Index
WILEY END USER LICENSE AGREEMENT
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Oral Healthcare and the Frail Elder
Second Edition
Edited by
Michael I. MacEntee
University of British Columbia
Vancouver, British Columbia, Canada
Frauke Müller
University of Geneva
Geneva, Switzerland
C. Peter Owen
University of the Witwatersrand
Johannesburg, South Africa
W. Murray Thomson
University of Otago
Dunedin, New Zealand
Copyright © 2025 by John Wiley & Sons, Inc. All rights reserved, including rights for text and data mining and training of artificial technologies or similar technologies.
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Foreword
Ronald L. Ettinger
College of Dentistry and Dental Clinics, University of Iowa, Iowa City, USA
It is now over 10 years since the first edition of Oral Healthcare and the Frail Elder was published. This edition is a significant expansion from the previous one. Interesting new chapters have been added and the emphasis has shifted from the clinical to a more philosophical and global approach.
The population of the US and Canada is aging. However, as people age, they are influenced by a variety of behaviors, such as poor diets, high sugar intakes, sedentary lifestyles which result in suboptimal exercise, and misuse of tobacco, alcohol, and drugs which lead to many chronic noncommunicable diseases (NCD). With age, the culmination of these diseases is frailty both systemic and oral. Another complicating factor, according to the WHO, which can lead to frailty is the persistent and pervasive advertising and influence of the sugar, alcohol, and tobacco industries as increased consumption of these products can cause a variety of NCDs. These systemic and oral diseases have long latency periods before the development of acute exacerbations, for which there is no cure.
Oral healthcare is unfortunately not uniformly accessible in most countries. The fact is that the most vulnerable members of our society are the most likely to face the greatest barriers for receiving inadequate oral healthcare. The impact of not caring for these oral noncommunicable diseases (dental caries, periodontitis, mucositis, tooth loss, and some cancers) in frail older adults is magnified and has an impact on the quality of their life, general health, and morbidity and mortality. Caries is the most prevalent of these diseases and in general, preventive programs in the frail population have been a failure. The relationship between periodontal disease and other NCDs such as diabetes, cardiovascular disease, dementia, and mortality has been intensely studied. This relationship may be that periodontal disease and these other diseases share age‐related inflammatory responses.
Unfortunately, total loss of teeth has been accepted in many cultures as the normal price of aging. In many frail older adults, the entry into long‐term care has been associated with a breakdown in the dentition. The incidence of oral precancers and cancers is significant in frail populations. The social, emotional, and biological consequences of oral NCDs in frail older adults are discussed in detail in this book.
The purpose of the book is to provide the reader with the functional knowledge needed to understand the frail older population and to help clinicians develop and provide evidence‐based care.
Preface: The Challenge of Aging and Frailty and Why a Second Edition?
Michael I. MacEntee
Faculty of Dentistry, University of British Columbia, Vancouver, British Columbia, Canada
I will apply the regimens of treatment according to my ability and judgment for the benefit of my patients and protect them from harm and injustice… [and] Into whatever house I enter; I will do so for the benefit of the sick…
Source: Adapted from the Hippocratic Oath, translation by Nicholas Dunkas, MD (Retsas, 2019)
Why a Second Edition?
It is 10 years since the first edition of this book appeared and much has happened. Above all, there is mounting evidence that the dental and other healthcare professions are beginning to approach the challenges of oral health and related care in old age differently and more constructively than we did a decade ago. This change is occurring slowly but progressively, and it has prompted an extensive reconsideration of the information in the first edition. Consequently, in constructing this new edition, we are responding to the following.
There has been a substantial increase over the last decade in the population of frail and disabled elders who need continuous, safe, effective transdisciplinary care at home for as long as possible, and in residential facilities where available as their frailty and dependency on others increase (
Table 1
).
Healthcare professions are now more aware than ever of these demographic and healthcare challenges as they search for their appropriate roles within the complicated environment of transdisciplinary care.
It is clear that mouthcare is integral to general health in all age groups and possibly even more with increasing frailty.
Knowledge of disease and disability has increased over the last decade, and many of the beliefs and recommendations in the original edition warrant revision to explain current challenges and barriers to oral health, and to better prepare dental and other professions for the needs and demands of frail elders.
Oral diseases sit prominently within the context of noncommunicable disease that the World Health Organization (
2020
) identifies as a major global challenge for human development, a leading cause of morbidity, and disproportionately burdensome within low‐income communities. Yet the curative interventions favored by the dental professions tend mainly to the biomedical demands of affluent communities (Watt et al.,
2019
).
There is a need in dental geriatrics for a global focus on the principles of population and public health and of equity in healthcare by acknowledging that oral healthcare succeeds only by recognizing that oral disease and disability are, like cardiovascular disease, diabetes, cancer, obesity, and other noncommunicable diseases, influenced strongly by the pervasive social and commercial determinants of health and unrelenting social inequalities (Benzian et al.,
2021
).
This new edition attends closely to these upstream determinants of health as the foundation underlying a broad range of strategies for effectively managing the oral healthcare of frail elders. We focus particularly on people who are frail and unable to access the usual dental services accessible to older people. This acknowledges the broad challenges of oral healthcare in the context of noncommunicable disease, and health equity as a compounding challenge to frailty. Our evidence is drawn from, and relevant to, the international community of clinicians, public health providers, educators, and researchers in the dental and other health professions. We provide information that is highly relevant to public health and residential care administrators, policy makers, nurses, nutritionists, speech therapists, and physicians attending elders who are home‐bound or in residential care.
Table 1 Five‐year probability of survival with low or high frailty and co‐morbidity.
Source: Adapted from Schoenborn et al. (2022).
Condition
Low frailty, no co‐morbidity
High frailty, high co‐morbidity
Age in years
75
80
85
75
80
85
Survival %
Women
93
88
78
65
58
44
Men
89
82
70
55
49
38
Overall, this book provides an evidence‐based foundation of clinical knowledge from a global perspective for managing the oral health of frail elders.
References
Benzian H, Guarnizo‐Herreño CC, Kearns C, Muriithi MW, Watt RG. (2021). The WHO global strategy for oral health: an opportunity for bold action.
Lancet
398:192–194. doi:
https://doi.org/10.1016/S0140‐6736(21)01404‐5
.
Retsas S. (2019). First do no harm: the impossible oath.
BMJ
366 doi:
https://doi.org/10.1136/bmj.l4734
Schoenborn NL, Blackford AL, Joshu CE, Boyd CM, Varadhan R. (2022). Life expectancy estimates based on comorbidities and frailty to inform preventive care.
J. Am. Geriatr. Soc.
70:99–109. doi:
https://doi.org/10.1111/jgs.17468
.
Watt RG, Daly B, Allison P, et al. (2019). Ending the neglect of global oral health: time for radical action.
Lancet
394(10194):261–272. doi:
https://doi.org/10.1016/S0140‐6736(19)31133‐X
.
World Health Organization (2020). Assessing national capacity for the prevention and control of noncommunicable diseases: report of the 2019 global survey.
www.who.int/publications/i/item/ncd‐ccs‐2019
.
Note
Artists: Emma T MacEntee and Sebastien A MacEntee
List of Contributors
Paul AllisonFaculty of Dental Medicine and Oral Health Sciences, McGill University, Montreal, Quebec, Canada
Fernanda AlmeidaFaculty of Dentistry, University of British Columbia, Vancouver, British Columbia, Canada
Maha M. Al‐SahanCollege of Dentistry, King Saud University, Riyadh, Saudi Arabia
Limor Avivi‐ArberFaculty of Dentistry, University of Toronto, Toronto, Ontario, Canada
B. Lynn BeattieFaculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
Pierre J. BlanchetFaculty of Dental Medicine, Universite de Montreal, Montreal, Quebec, Canada
Michael M. BornsteinUniversity Centre for Dental Medicine Basel UZB, University of Basel, Basel, Switzerland
Mario A. BrondaniFaculty of Dentistry, University of British Columbia, Vancouver, British Columbia, Canada
Elaine CardosoFaculty of Dentistry, University of Toronto, Toronto, Ontario, Canada
Najla ChebibUniversity Clinics of Dental Medicine, University of Geneva, Geneva, Switzerland
Nico CreugersRadboud University Medical Center Nijmegen, Nijmegen, The Netherlands
Alan A. DeutschFaculty of Medicine and Health, University of Sydney, New South Wales, Australia
Shafik DharamsiUniversity of North Texas Health Science Center, Fort Worth, TX, USA
Leeann DonnellyFaculty of Dentistry, University of British Columbia, Vancouver, British Columbia, Canada
Joke DuyckDepartment of Oral Health Sciences, University Hospitals Leuven, Leuven, Belgium
Michael B. GoldbergFaculty of Dentistry, University of Toronto, Toronto, Ontario, Canada
Fernando Neves HugoFaculty of Dentistry, New York University, NY, USA
Laura HurdSchool of Human Kinetics, University of British Columbia, Vancouver, British Columbia, Canada
Kazunori IkebeFaculty of Dentistry, Osaka University, Osaka, Japan
Barbara JanssensDepartment of Dentistry, University of Ghent, Ghent, Belgium
Arminee KazanjianFaculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
Matana Kettratad‐PruksapongFaculty of Dentistry, Thammasat University, Bangkok, Thailand
Shiva KhatamiART Orthodontics, Davie, FL, USA
Jim Yuan LaiFaculty of Dentistry, University of Toronto, Toronto, Ontario, Canada
Denise LarondeFaculty of Dentistry, University of British Columbia, Vancouver, British Columbia, Canada
Gilles J. LavigneFaculty of Dental Medicine, Universite de Montreal, Montreal, Quebec, Canada
David MacDonaldFaculty of Dentistry, University of British Columbia, Vancouver, British Columbia, Canada
Michael I. MacEnteeFaculty of Dentistry, University of British Columbia, Vancouver, British Columbia, Canada
Jirakate Madiloggovit‐LowerFaculty of Dentistry, Thammasat University, Bangkok, Thailand
Sabrina ManiewiczFaculty of Medicine, University of Geneva, Geneva, Switzerland
Leonardo MarchiniCollege of Dentistry, University of Iowa, Iowa City, IA, USA
Rodrigo MarinoMelbourne Dental School, Melbourne, Victoria, Australia
Gerald McKennaSchool of Medicine, Dentistry and Biomedical Sciences, Queens University Belfast, Belfast, UK
Mary E. McNallyFaculties of Dentistry & Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
Victor MinichielloSchool of Social Justice, Queensland University of Technology, Brisbane, Australia
Philippe MojonFaculty of Medicine, University of Geneva, Geneva, Switzerland
Pedro Molinero‐MourelleSchool of Dental Medicine, University of Bern, Bern, Switzerland, and Faculty of Dentistry, Complutense University of Madrid, Madrid, Spain
Matshediso Mothopi‐PeriSchool of Oral Health Sciences, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
Paula MoynihanFaculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
Frauke MüllerUniversity Clinics of Dental Medicine, University of Geneva, Geneva, Switzerland
Dominique NiestenCollege of Dental Science, Radboud University Medical Center Nijmegen, Nijmegen, The Netherlands
C. Peter OwenSchool of Oral Health Sciences, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
Alison PhinneySchool of Nursing, University of British Columbia, Vancouver, British Columbia, Canada
Martin SchimmelSchool of Dental Medicine, University of Bern, Bern, Switzerland
Barry J. SessleFaculty of Dentistry, University of Toronto, Toronto, Ontario, Canada
Linda Slack‐SmithSchool of Population and Global Health, University of Western Australia, Crawley, Western Australia, Australia
Moira B. SmithDepartment of Public Health, University of Otago, Wellington School of Medicine, Wellington, New Zealand
Frankie Hon Ching SoSpecialist in Community Dentistry, Hong Kong
Stephen SonisSchool of Dental Medicine, Harvard University, Boston, MA, USA
Murali SrinivasanCenter for Dental Medicine, University of Zurich, Zurich, Switzerland
Howard C. TenenbaumFaculty of Dentistry, University of Toronto, Toronto, Ontario, Canada
Gladys Meriting ThokoaneSchool of Oral Health Sciences, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
W. Murray ThomsonFaculty of Dentistry, University of Otago, Dunedin, New Zealand
Shunhau ToFaculty of Dentistry, University of British Columbia, Vancouver, British Columbia, Canada
Nicholas TongFaculty of Dentistry, University of British Columbia, Vancouver, British Columbia, Canada
Bruce WallaceSchool of Social Work, University of Victoria, Vancouver, British Columbia, Canada
Shane WhiteUCLA School of Dentistry, University of California, Los Angeles, CA, USA
Michael WisemanFaculty of Dental Medicine, McGill University, Montreal, Quebec, Canada
F.A. Clive WrightCentre for Education and Research on Ageing, Concord Clinical School, University of Sydney, Concord, New South Wales, Australia
Chris WyattFaculty of Dentistry, University of British Columbia, Vancouver, British Columbia, Canada
Chao Shu YaoQ and M Dental Group, Singapore
Rena ZeligSchool of Health Professions, Rutgers University, Newark, NJ, USA
1Demography of Aging and Frailty, and the Epidemiology of Oral Conditions
W. Murray Thomson1, Moira B. Smith2, Fernando Neves Hugo3, and Philippe Mojon4
1 Faculty of Dentistry, University of Otago, Dunedin, New Zealand
2 Department of Public Health, University of Otago, Wellington School of Medicine, Wellington, New Zealand
3 Faculty of Dentistry, New York University, New York, NY, USA
4 Faculty of Medicine, University of Geneva, Geneva, Switzerland
This chapter covers the population aspects of aging and oral health. First, we consider the demography of aging and frailty, followed by a look at the aging process itself. Multimorbidity and frailty, including the notion of oral frailty, are described. We also provide an epidemiological overview of the common oral conditions, including tooth loss, dental caries, periodontitis, dry mouth, oral mucosal lesions, and temporomandibular disorders.
Demography of Aging and Frailty
The Aging Population
Worldwide, increased life expectancy and falling birth rates, which are largely a consequence of improved public health actions, have meant that the number and proportion of older people in many countries have increased. This rise has been rapid and is expected to continue. By 2050, 2.1 billion people, or 1 in 6, will be aged over 60 years, which is double the current older population. Within that group, the oldest‐old (≥85 years) will increase the most, tripling current levels by 2050. While the age‐related demographic changes up to now have predominantly occurred in high‐income countries, it is the low‐ and middle‐income countries where growth is expected in the future; by 2050, two‐thirds of the global older population will reside in low‐ and middle‐income countries.
Conceptualizing Aging
Aging is an inevitable feature of the human experience. Efforts to understand it have resulted in a plethora of explanatory biological and social theories (Table 1.1). No single theory fully explains aging, which underlines its complex and multifactorial nature. Moreover, the biological events involved in aging take place within social norms and societal contexts, which themselves show considerable variation.
Table 1.1 Theories of aging.
Theory
Brief description
Biological theories
a
Replicative senescence
Somatic cells are capable of a finite number of divisions.
Accumulated mutation
Accumulation of somatic damage from “wear and tear” and compromised repair of DNA.
Antagonistic pleiotropy
Genes favoring survival in youth at the cost of harm in old age.
Disposable soma
Biological priority to perpetuate the species is followed by ineffective repair and maintenance of somatic cells when reproduction is complete.
Social theories
b
Activity theory
Participation in enjoyable social activities promotes health and satisfaction in old age.
Disengagement theory
Gradual withdrawal from previously held roles benefits both the individual and society.
Continuity theory
Substitution of new roles for past activities and responsibilities as adaptation to age‐associated changes occur. This challenges both activity theory and disengagement theory.
a Adapted from Lipsky and King (2015).
b Adapted from Hasworth and Cannon (2015).
While we all age at the same rate chronologically, there is considerable variation in rates of biological aging. Elliott et al. (2021) recently characterized and described differences in the pace of aging among participants followed to age 45 years in the Dunedin Multidisciplinary Health and Development Study, a prospective study which (to date) has followed a complete birth cohort to midlife. Using a composite measure assembled from 19 different biomarkers representing the cardiovascular, metabolic, renal, immune function, oral, and pulmonary domains, the pace of aging in the cohort was found to range from 0.4 to 2.4 biological years per chronological year. Participants who were aging faster already had poorer cognitive and sensorimotor function, along with anatomical evidence of higher brain age and central nervous system degeneration assessed using magnetic resonance scans. That these differences were already apparent by age 45 means that noncommunicable disease (NCD) trajectories are already well‐established by midlife. They arise from individual differences in genetic endowment, cellular biology, life‐experiences and exposures. Such aging has usually involved decades of subclinical decline—in, variously, the cardiovascular, metabolic, renal, immunological, neurological, and pulmonary organ systems—prior to clinical manifestation, diagnosis, and management later in life. Thus, as people pass through late middle age and into old age, their ongoing decline manifests as a steadily accumulating number of chronic conditions requiring medical or surgical intervention (Thomson, 2023).
Multimorbidity
Multimorbidity is defined as the co‐existence of two or more conditions in the same individual (Jose et al., 2009). Conditions that commonly cluster include diabetes, hypertension, osteoarthritis, dementia, dyslipidaemia, depression, heart failure, and cancer (Ofori‐Asenso et al., 2018; Skou et al., 2022). Estimates of multimorbidity vary according to the data source and how it is defined (Gontijo Guerra et al., 2019; Johnston et al., 2019). Recent metaanalyses provide a global prevalence ranging from 37.2% in the community (Chowdhury et al., 2023) to 42.4% in a combination of community and healthcare settings (Ho et al., 2022). Disparities in the prevalence of multimorbidity by gender, socioeconomic status, and ethnicity are evident, with higher prevalence among women, those living in deprivation, and in indigenous and ethnic minority groups (Stanley et al., 2018; Quiñones et al., 2021; Alshakhs et al., 2022; Ho et al., 2022; Chowdhury et al., 2023).
The prevalence of multimorbidity also increases with age, a consequence of the slow progression of chronic conditions and longer life‐expectancy, and (in turn) the high prevalence of chronic conditions among older people. Most people aged over 60—and virtually all of the oldest old—live with two or more chronic conditions (Ofori‐Asenso et al., 2018; Ho et al., 2022; Chowdhury et al., 2023). The number of conditions also rises with age (Chowdhury et al., 2023). The combination of population aging and the rising prevalence of chronic conditions means that multimorbidity is a substantial global public health concern (Pearson‐Stuttard, et al., 2019).
Multimorbidity has considerable consequences for older people, including functional decline and greater disability, poor quality of life, a higher risk of hospitalization and longer hospital stays, polypharmacy, and premature death (Skou et al., 2022). There are also implications for their families, communities, health systems, and society. Individuals with multimorbidity rely on family members and others to support the usual activities of daily living (ADL), which can range from shopping and housework to full personal care. For the health system, the substantial expenditure associated with high health service‐use, including health and social care, is a considerable burden (Skou et al., 2022; Tran et al., 2022). Managing the care of someone with multimorbidity is complex, requiring a well‐coordinated, comprehensive, and person‐centered approach (Whitty et al., 2020; Skou et al., 2022). Treating each condition singly typically results in inadequate and inefficient care, and a high probability of iatrogenic damage through polypharmacy. Apparently, the cost of caring for someone with multimorbidity is greater than that for each single condition combined (Tran et al., 2022).
As the proportion of older people in the population continues to rise, so too will the demand on health and social services, along with associated financial costs (Prince et al., 2015). Given that most health and social services are underresourced, especially in low‐ and middle‐income countries, and inadequately prepared, it is challenging to appropriately addressing the future needs of people with multimorbidity.
Chronic conditions are patterned by exposure over time to a range of risks, such as environmental, social, and workplace influences, and the individual behaviors resulting from those exposures, including diet, physical activity, use of tobacco and alcohol, and poor access to health services (Marmot, 2005; Peters et al., 2019).
Frailty
Frailty is closely related to aging. It arises from a decline in functioning in multiple physiological systems, with a resultant higher vulnerability to stressors. Frailty is characterized by a loss of biological reserves, a failure of physiological mechanisms, and vulnerability to a range of adversities, including multimorbidity, cognitive decline, late‐life dependency, and premature death. Conceptually and physically, it overlaps with disability and the accumulated burden of NCDs. There are two widely cited conceptual approaches to measuring frailty (Walston, 2021): the model of physical frailty, characterized as a phenotype arising from the loss of biological reserve with subsequent weakness, fatigue, weight loss, and slowing down; and the model of deficit accumulation, understood as the accumulation of deficits from illnesses and disability, along with cognitive and functional decline, that drives frailty.
The global prevalence of frailty remains unclear, owing to such classification differences and a lack of nationally representative data. A recent systematic review of available population‐level studies from 62 countries indicated a prevalence for frailty of between 1 in 8 and 1 in 4 older adults, with little change in prevalence since 2012 (O'Caoimh et al., 2021). It also highlighted pre‐frailty as a recognized prodromal state before the onset of clinically identifiable frailty, with sarcopenia in old age as a key precursor. There was an overall estimate of 12% for physical frailty and 24% for the deficit accumulation model. For pre‐frailty, the respective estimates were 46% and 49%. These estimates underline the importance of frailty as a gerontological state.
Oral Frailty
The concept of “oral frailty” has emerged in recent years with the term “oral hypofunction” applied to the oral manifestations of aging‐associated sarcopenia and dry mouth (Minakuchi et al., 2018). Oral hypofunction is determined by identifying seven clinical signs; five represent functional aspects of oral musculature and two represent bacterial counts and moisture on the dorsum of the tongue. While it remains unclear whether the concept implies a syndrome, there is the possibility that treating oral hypofunction could help slow the rate of onset of general frailty. It is noteworthy that, in the absence of convincing evidence of its efficacy from interventional studies, the treatment of oral hypofunction has already been included in the Japanese dental payment schedule. At this early stage, questions remain about the validity of this approach, and whether its philosophical basis fits with contemporary biopsychosocial concepts of positive aging.
Importance of the Life‐Course
Appreciating the life‐course journey is crucial to understanding aging and oral health. The dental literature on older people has almost exclusively focused on the personal behaviors and exposures leading to the burden of chronic oral conditions, without considering the course of life leading to a particular point in time. Such a narrow focus has not been helpful, enabling misinterpretation of much of the available evidence. A wider perspective is needed and, when considered, has revealed that the circumstances and consequences of the past typically have a lasting effect on developments throughout life (Gilleard and Higgs, 2016; Heckhausen and Wrosch, 2016; MacEntee et al., 2019; Thomson, 2023).
People with what we would consider to be “good oral health” in old age are those who have adapted successfully to the burden of their oral disease, accumulated over the years. They are able to chew, taste, and enjoy their food, and to smile and speak comfortably and without social embarrassment (MacEntee et al., 1997; Locker, 1988). They may have retained most of their natural teeth, maybe they are complete denture‐wearers, or they may have a combination of these. Successful oral aging cannot be defined solely by the outdated concept of a complete dentition, that is, whether someone is with or without teeth or their replacements.
Thus, the concept of adequate oral functioning is considerably broader than the biomedical notions which have largely predominated to date (McGrath et al., 2022). Given the value placed by older people on social engagement, independence, physical health, and positive attitudes (Reich et al., 2020), having a mouth and dentition that enables those is important. Accordingly, a biopsychosocial and functional concept is more appropriate, given the wide variation in biological status observed in older populations. The biopsychosocial model emphasizes the interconnections among biological, psychological and socioenvironmental factors in determining health states, and it is consistent with the definition of healthy aging as “developing and maintaining the functional ability that enables well‐being in older age” (World Health Organization, 2015). Understanding how people's health develops is critical to understanding and accepting the biopsychosocial model of oral health in old age.
It can be helpful to consider the three types of capital pertaining to the resources used to achieve and maintain health (Frytak et al., 2002). Financial capital is someone's income and wealth, upon which consumption of health‐promoting goods is highly dependent. Human capital is the investments in education and training that enable people to avoid risky exposures or behaviors. Social capital comprises their personal relationships and interactions. Using experiences with dental caries as a simple example, financial capital enables the purchase of fluorided toothpaste and a healthier diet, together with being able to afford ongoing maintenance of the dentition; human capital enables the long‐term practice of a health‐promoting behavior, such as twice‐daily toothbrushing; and social capital would be apparent through the social norm of having clean white teeth, and a full complement of anterior teeth (Thomson, 2023).
Being operative day after day over many decades of life, the three forms of capital favor less dental caries and more tooth retention. Comparing people with more capital against those with less capital at any age during the life‐course will show marked differences in rates of oral disease and in numbers of missing teeth. Comparisons at older ages will show greater differences, consistent with the cumulative nature of both exposure and outcome. An appreciation of such processes is crucial for understanding and interpreting epidemiological data on the oral status of older people.
Epidemiology of Oral Conditions in Older People
Tooth loss, dental caries, periodontitis, dry mouth, oral mucosal lesions, and musculoskeletal disorders are the most impactful oral conditions observed in older populations (Kassebaum et al., 2017). They are all chronic and noncommunicable. The more common chronic oral conditions, such as dental caries and periodontitis, are cumulative in nature, which means that their extent and severity generally increase with age. Tooth loss can be a consequence of either condition, which makes the interpretation of dental epidemiological information on dental caries and periodontitis challenging. The complication arises from the fact that, as teeth are gradually lost over time because of either of those conditions, the remaining teeth are essentially the healthy survivors. The same issue arises at the personal level, whereby people living into their seventh decade and beyond are relatively healthy survivors, and differ in important and meaningful ways from those who did not survive. Consider also the cumulative nature of dental caries, periodontitis and consequent tooth loss, where the earliest exposures to the various causes will have commenced very distally indeed and then accrued day by day, week by week, month by month as the life‐course unfolded.
All these considerations make the interpretation of oral epidemiological data on older people a complicated exercise, fraught with difficulties. In the sections which follow, we summarize what is currently known about the occurrence of tooth loss, dental caries, periodontitis, dry mouth, oral mucosal lesions, and musculoskeletal disorders in older populations.
Edentulism and Incremental Tooth Loss
Edentulism is the state of having had all natural teeth removed. By contrast, incremental tooth loss is the gradual loss of teeth, whether due to dental caries, severe periodontitis, orofacial trauma or other reasons, as people move through life. People who are edentate have had all their remaining natural teeth removed, usually after many years of incremental tooth loss, which is as much a social as a clinical decision (Sanders et al., 2004; Sussex et al., 2010; Gibson et al., 2017; Goulart et al., 2019). It requires the patient and dentist to have colluded in the decision to remove the remaining teeth. Edentulism is usually considered by dentists to be an undesirable, “biographically disruptive” endpoint representing the failure of both self‐care and the dental care system (Rousseau et al., 2014), but the transition to edentulism can also mark the end of decades of misery and eating problems with impaired natural teeth (Thomson, 2014).
The combination of disease‐related and sociocultural influences makes complete tooth loss a complex phenomenon. It is relatively easy to measure, usually by self‐reports, which obviates the need for the systematic and detailed clinical examination (Gilbert et al., 1999; Høvik et al., 2022). Accordingly, edentulism has been the focus of much investigation, with a search on PubMed revealing almost 2000 articles published between 1983 and 2023, with two peaks in published reports in 2015–2018 and 2021–2022.
Edentulism is strongly and positively associated with age (Slade et al., 2014; Ren et al., 2017). For example, in Switzerland in 2012, fewer than 1 in 100 of those younger than 45 years were edentate, in contrast to about 1 in 10 of 75–84 year olds (Schneider et al., 2017). In China at that time, fewer than 1 in 50 aged 45–54 years and about one‐third of those aged 75 or more were edentate (Ren et al., 2017). In Brazil, while 6% of the overall adult population were edentate in 2010, it was 77% among older people (Cardoso et al., 2016).
There are also marked socioeconomic and education‐level differences in complete tooth loss, observable in both cross‐national comparisons (Tyrovolas et al., 2016; Borg‐Bartolo et al., 2022) and within‐country investigations (Suominen‐Taipale et al., 1999; Olofsson et al., 2018). There are also large differences in tooth loss by income among countries (Tyrovolas et al., 2016), whereby the prevalence of edentulism in countries with Gross National Income <$15,000 is about one‐third higher than in countries where the Gross National Income is >$45,000. Moreover, tooth loss is increasing in low‐ and middle‐income countries while continuing to decrease in high‐income countries. It is also more prevalent in rural than urban populations (Sussex, 2008), and where dental services are readily accessible (Mojon, 2003; Winkelmann et al., 2022).
The prevalence of complete tooth loss has decreased in recent decades by about 1% every year in high‐income countries for various reasons, but that decline has leveled off recently, contrary to earlier predictions (Suominen‐Taipale et al., 1999; Mojon et al., 2004; Thomson, 2012; Slade et al., 2014; Cardoso et al., 2016). For example, among Swiss 65–74 year olds, the annual decline in edentulism between 1992 and 2002 was around 1.1%, but it was only 0.8% for the following decade (Schneider et al., 2017). Without much doubt, very few young adults in wealthy countries today lose all their natural teeth; however, complete tooth loss from the maxilla is likely to remain highly prevalent for the foreseeable future, and especially in older populations (Cardoso et al., 2016).
There are notable social influences on the occurrence of incremental tooth loss, defined as the unplanned, episodic loss of some but not all natural teeth. Very few people reach old age without losing one or more teeth. For example, there is a wide diversity of residual dentitions and associated use of dentures among older New Zealanders, but rarely are there completely intact dentitions in this age group (Hyland et al., 2019, 2022). A number of cohort studies of older adults demonstrated that incremental tooth loss continues in people aged 65 or older (Drake et al., 1995; Locker et al., 1996; Slade et al., 1997; Gilbert et al., 1999; Warren et al., 2002; De Marchi et al., 2012).
In high‐income European countries, there has been a decline in the proportion of adults with 1–5 teeth missing (Suominen‐Taipale et al., 1999; Unell et al., 2015; Schneider et al., 2017). While diseases play an important role in the incremental loss of teeth, on many occasions is to prevent future pain, to lower the cost associated with dental treatment, or to minimize the anxiety caused by dental treatment (Bouma et al., 1987). Cultural factors, including societal norms and beliefs about oral health, play an important role in decisions about dental treatment and losing teeth (Roberto et al., 2019).
Dental Caries
The typical annual caries increment in the permanent dentition remains reasonably constant through life, with an average of about one new demineralized dental surface per year in the average person (Broadbent et al., 2013). That one‐surface increment rate is seen in older people living in their own homes, mostly involving coronal rather than root surfaces (Griffin et al., 2004; Thomson, 2004).
After admission to residential care, the caries increment increases considerably to the point where it is more than double that observed among older people dwelling unrestricted in the community (Chalmers et al., 2005). Among those with dementia, it is more than twice that rate again, at almost five new surfaces affected per year, and clinicians who work with people who have dementia have plenty of tales of carious dentitions deteriorating rapidly. Earlier reports from small longitudinal studies also highlighted the problem of higher caries increments among groups in residential care or with dementia (MacEntee et al., 1990; Jones et al., 1993). It is somewhat curious that not much prospective observational research has been undertaken to investigate increments of dental caries among cognitively impaired residents. Such research is, of course, very challenging.
Chapters 2 and 15 have more detailed information on dental caries as a NCD in old and frail people.
Periodontitis
Periodontitis is a chronic inflammatory condition in which a host‐mediated immune response to dysbiosis in the subgingival bacterial biofilm causes progressive destruction of the periodontal tissues, including alveolar bone, resulting in loss of periodontal attachment and associated structures (Tonetti et al., 2018). During the life‐course, loss of periodontal attachment becomes apparent during the early 20s and increases steadily through middle age, manifesting mainly as increases in the depth and extent of periodontal pockets, particularly among tobacco smokers (Zeng et al., 2014). By old age, the majority of new periodontal attachment loss tends to appear as gingival recession rather than as pocketing (Beck et al., 1997; Thomson, 2004). That process makes previously unexposed root surfaces susceptible to root surface caries (Clark et al., 2021).
Consequently, most older people with natural teeth have at least moderate levels of attachment loss (Locker et al., 1998), although a substantial minority have more advanced loss, usually in a few isolated sites (Eke et al., 2016). As discussed above, interpreting periodontal data from older people is complicated by the fact that their past experience of incremental tooth loss means that the teeth surviving into old age are also likely to have had less severe periodontitis over their lifetime. Thus, a clinical periodontal examination undertaken in old age is likely to underestimate the individual's lifetime experience of periodontitis (Persson, 2017).
Oral Mucosal Lesions
Oral mucosal lesions are a large, heterogeneous group of disorders with distinct causes that include, among others, lesions of inflammatory and infectious origins, reactive lesions, potentially malignant lesions, and oral cancer. Prior studies on the overall prevalence of oral mucosa lesions using probabilistic samples are somewhat scarce, and reports show conflicting findings ranging from 12% to 87%, likely due to differences in diagnostic criteria and sampling strategies. Irrespective of these methodological issues, the findings indicate that oral mucosa lesions are more prevalent in older adults than in any other age group (Lin et al., 2001). While aging per se does not cause significant changes in the oral mucosa, the clinical appearance of the mucosa can change because of sustained exposure to local factors (Radwan‐Oczko et al., 2022) that include, among others, mechanical trauma, reduced salivary flow, and tobacco use (Rivera and Arenas‐Márquez, 2017).
Of the various oral mucosal lesions, potentially malignant disorders are a group of morphological alterations that can have a greater potential for malignant transformation of significant clinical relevance. Not only are they more prevalent in older people, but they also suggest a higher risk of malignancies elsewhere in the oral mucosa. They include oral leukoplakia and subtypes erythroleukoplakia and proliferative verrucous leukoplakia, oral erythroplakia, palatal lesions in reverse‐smokers, oral submucous fibrosis, actinic keratosis, lichen planus, discoid lupus erythematosus, dyskeratosis congenita, and epidermolysis bullosa (Warnakulasuriya et al., 2007; van der Waal, 2009).
The most frequently observed lesions in order of prevalence are traumatic ulcers, lichen planus, irritation fibroma, melanotic pigmentations, recurrent aphthous stomatitis, angular cheilitis, benign migratory glossitis, denture‐related stomatitis, frictional keratosis, haemangioma, atrophic glossitis, leukoplakia, and nicotine stomatitis (Rivera et al., 2017). However, the majority of the studies identified in that review used nonrepresentative samples, and so the true prevalence of the lesions remains unclear because of important selection bias. Nonetheless, there is reasonably robust evidence that higher age, smoking, and heavy alcohol consumption are associated with higher rates of potentially malignant disorders, while greater age, lower socioeconomic status, higher alcohol intake, and the use of removable dentures are associated with higher rates of proliferative non‐neoplastic lesions and benign neoplasms (Carrard et al., 2011).
Oral cancers are a group of neoplasms affecting different sites of the head and neck. While there is some variation in the literature relating to the specific sites included in classifications of oral cancer, this chapter uses the classification proposed by the Global Burden of Disease Study (Global Burden of Disease 2019 Cancer Collaboration et al., 2022). It includes malignant neoplasms of lip, base of tongue, other and unspecified parts of tongue, gum, floor of mouth, palate, other and unspecified parts of mouth, parotid gland, and other and unspecified major salivary glands (ICD‐10 C00–C08). There is an important distinction between cancer of the mouth and oropharyngeal cancer because of the increasing importance of HPV in the etiology of the latter (Conway et al., 2018).
In 2019, there were approximately 390,000 new cases and 194,000 deaths due to oral cancer globally, and of those, approximately 111 million new cases and 72 thousand deaths occurred in people aged >70 years (Global Burden of Disease 2019 Cancer Collaboration et al., 2022). Furthermore, between 1990 and 2019, there was a substantial increase in deaths from oral cancer among people >70 years—from 1.32/100,000 (95% uncertainty interval [UI] 1.24–1.42) to 1.75/100,000 (95% UI 1.58–1.93). This increase was more apparent in low‐ and medium‐income regions (1.79/100,000, 95% UI 1.57–2.05), while death rates in high‐income regions were more stable (1.61/100,000, 95% UI 1.58–1.64 in 1990). Oral cancer incidence rates also increased for people aged >70 years in the period—from 2.57/100.00 (95% IU 2.45–2.71) in 1990 to 3.61 (95% IU 3.28–3.94) in 2019. Similar to mortality rates, this increase was concentrated in low‐ and medium‐income regions (Global Burden of Disease 2019 Cancer Collaboration et al., 2022).
Disability from oral cancer, as expressed by disability‐adjusted life‐years (DALY) rates, also increased significantly between 1990 and 2019 among people >70 years of age, especially in low‐ and middle‐income countries. In 1990, the global DALY/100,000 population rate was 11.5 (95% IU 10.8–12.4) while, in 2019 the rate was 15.9 (95% IU 14.3–17.5). As with mortality and incidence, the increase in DALY rates has been occurring especially in regions of intermediate development (Global Burden of Disease 2019 Cancer Collaboration et al., 2022).
Please see Chapter 3 for additional information about oral cancer and associated lesions.
Dry Mouth
An important contributor to impaired quality of life among older people, dry mouth is moderately prevalent. Please see Chapter 12 for further information about dry mouth in older populations.
Muscular and Joint Disorders
Temporomandibular dysfunctions (TMD) are a group of disorders affecting masticatory muscles, the temporomandibular joint (TMJ) and the surrounding bones and soft tissues (Orofacial Pain Classification Committee of the International Headache Society, 2020). They are characterized by pain affecting the TMJ and masticatory muscles in that region. TMDs are chronic and recurrent, and include functional problems such as jaw opening limitation, deviant jaw movement patterns or joint sounds (clicking or crepitus), with pain as the dominant presenting symptom.
Prior to the 1990s, understanding of TMD occurrence was focused on the pathophysiological characteristics of the disorders. Subsequently, a method to classify TMDs was proposed by Dworkin and LeResche (1992), representing a landmark in clinical‐epidemiological research in the area. The classification categorized TMD into three groups: (i) muscle disorders; (ii) disk disorders; and (iii) joint disorders.
Temporomandibular joint degeneration is more common with aging, and characterized by inflammatory‐degenerative joint disorders (Manfredini et al., 2010). In older adults, TMD‐related symptoms tend to reduce, while clinical signs tend to increase, which suggests that deterioration in masticatory function and the presence of pain tends to resolve with advancing age (MacEntee et al., 1987; Carlsson et al., 2014).
