Dental caries is one of the most prevalent chronic non-communicable diseases in the world, and the older population is at a disproportionately high risk. In the United States, the Centers for Disease Control and Prevention estimates that 96% of the population age 65 and over suffers from dental caries. In addition, in general, institutionalized elders are at greater risk than non-institutionalized.
With adults 65 and older set to represent 14% of the global population by 2040, it is essential that dental professionals understand the unique ways in which nutrition affects caries risk in the older population.
While diet affects caries risk in all age groups, it presents a particularly high risk in the geriatric population. We also know that the aging process can bring about numerous changes in the oral cavity, for example, reduced salivary flow and altered salivary composition due to factors such as systemic diseases, medications and hormonal changes. Outlined below are ways in which nutrition can affect caries risk, both on its own and through its interaction with other risk factors.
Older patients are more likely to favor foods with soft, smooth or moist textures over dry, fibrous or hard foods. This can be attributed to chewing and swallowing difficulties caused by reduced salivary flow, masticatory muscle weakness, oral lesions, or missing or loose teeth. While foods that are soft, moist and/or smooth are easier to chew and swallow, they are often high in fermentable carbohydrates and thus present a greater caries risk. Additionally, stagnation of the food bolus tends to occur in contact with the labial surfaces of the teeth, especially in the premolar-molar area.
For other patients, physical or cognitive difficulties (e.g., arthritis, dementia) may make it harder to shop for, prepare and eat more complex foods, and they may rely on convenience foods and snacks instead that contain high levels of fermentable carbohydrates.
Older patients often prefer smaller, more frequent meals and snacks, as opposed to larger meals. For some, this may be due to age-related changes in appetite and metabolism. In some cases, patients may also have been advised to eat less at each meal but to eat more often. Unfortunately for our older patients, caries risk is closely associated with increased eating frequency as well as increased sugar intake and consumption of other fermentable carbohydrates.
As previously mentioned, impaired salivary function can make chewing, lubricating and swallowing food more difficult. Reduced salivary flow also reduces the ability to clear food debris, buffer acidity in the oral cavity, and to remineralize dental hard tissues if demineralization has occurred. All of these factors increase caries risk. Exposed roots are particularly vulnerable to acid attacks, with root caries common in elderly patients. In addition, a lower intraoral pH promotes biofilm accumulation.
Oral Hygiene challenges
Elderly patients with physical or cognitive difficulties may lack the capacity to perform adequate oral hygiene by themselves. Without adequate hygiene, debris and biofilm can accumulate in interdental spaces, periodontal pockets, over exposed root surfaces which may be difficult to access, poorly maintained prostheses — all common in old age.
1. Perform a thorough risk assessment
The American College of Prosthodontists recommends using the Caries Management by Risk Assessment (CAMBRA) questionnaire to gauge caries risk and develop a treatment protocol. In elderly patients, they advise that preventative measures should take priority over operative treatments.
2. Provide therapeutic fluorides
For high-risk elderly patients, use of a high-level (prescription level) fluoride toothpaste such as Colgate PreviDent 5000 Booster Plus (Colgate Duraphat 5000) offers enhanced remineralization and caries protection. High-level fluoride toothpaste containing 5000 ppm fluoride has been shown to arrest and reverse early caries lesions. For patients with xerostomia, you can recommend the specially formulated Colgate PreviDent 5000 Dry Mouth Toothpaste.
In-office application of fluoride varnish is also recommended two to four times a year for patients at elevated risk of dental caries. One option is Colgate PreviDent Varnish (Colgate Duraphat Varnish).
3. Provide nutritional advice, keeping it simple and actionable
Nutritional counseling is a cornerstone of caries prevention. Patients and caregivers should be educated on the interaction between diet and caries risk. Bearing in mind that older patients may have socioeconomic, physical or cognitive barriers to compliance, and may also be managing the burden of other chronic illnesses, nutritional advice should be simple, memorable and easy to act on.
It is important to work closely with care teams to ensure that caries risk is considered and managed as part of the patient’s nutritional support.
4. Support oral hygiene
Patients and caregivers should be shown how to perform adequate oral hygiene and provided with suitable recommendations. For example, patients (or their caregivers on their behalf) may benefit from using an electric brush for oral hygiene, such as the Colgate hum.