The Age of Dentistry
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The Jogging Granny
If dental students remember nothing else from Professor Carole Palmer's lecture on nutrition and aging, they remember this: Palmer dressed in a white wig, granny glasses and sneakers taking a brisk jog around the classroom. The character, based on her vibrant aunt, who lived to be 93, is a reminder that the aging process varies from person to person.
"Please don't stereotype anybody," says Palmer, G69, N69. "Some people are very old when they are young; some are young when they are old. Some of it is health issues. Some of it is genetics. Some of it is lifestyle. Some of it is attitude. A lot of it is unknown.
"What you don't want to do is make an assumption based on your knowledge of your grandmother," she says. "There are senior citizens running marathons today."
Palmer is not surprised when dental students make assumptions about doddering old folks. ("When you're twenty, fifty is old," she says.) Yet there are misconceptions on both sides of the age divide. Many senior citizens themselves believe the myths about aging: That your mouth dries up just because you're old. That you eventually lose all your teeth. That once you get dentures, you no longer need to go to the dentist.
Research in recent years has disproved those beliefs and shown how crucial dental care is to the quality of life as we age. Take nutrition. Thanks to Tufts researchers like Papas, we now know that missing teeth or ill-fitting dentures can have a huge impact on dietary quality. In collaboration with researchers from the Jean Mayer USDA Human Nutrition Research Center on Aging at Tufts, Papas examined the relationship between tooth loss and nutrition in 691 elderly mostly Caucasian Bostonians. The team asked volunteers to fill out lifestyle surveys, which asked, among other things, whether they wore full or partial dentures. The researchers drew their blood and asked them to keep three-day food diaries.
After analyzing the data, Papas and her Tufts colleagues, including Palmer, Maureen Rounds and Robert Russell, found that denture-wearers reported significantly more difficulty eating. Not surprisingly, men who wore dentures consumed far less vitamin A, vitamin C, vitamin B6, folate, protein and calcium than their counterparts, while denture-wearing women took in less calcium and protein than their peers. Worse, a follow-up study six years later showed the denture-wearers were more likely to have died than those without dentures. About 80 percent of denture-wearers survived the six-year span compared with more than 90 percent of the dentate study subjects.
Why would this be? After all, "a soft diet can be perfectly healthy," Palmer says. People who have trouble chewing steak can switch to hamburger; if raw carrots are difficult to chew, cooked carrots will do the job. But too often, older adults fall into the "tea-and-toast" syndrome, where soft foods like toast, muffins and donuts become the fallback, washed down with sips of coffee or tea. As their nutrition declines, they may start to feel more fatigued or ill, symptoms they may write off as just another part of getting older.
Published in the journal Special Care in Dentistry in 1998, this landmark study underscores the importance of keeping your teeth as long as possible.
Papas' research has also improved our understanding of dry mouth. Once thought to be an inevitable result of aging, dry mouth is most often a side effect of what you'll find in a senior citizen's medicine cabinet: prescription drugs. More than 700 medications cause dry mouth, or xerostomia, the decreased salivary flow that puts teeth at higher risk for decay. Among the culprits are the pills commonly taken to manage cholesterol, hypertension, asthma and depression.
Drugs are not the only cause. For about 4 million Americans over age 40, an autoimmune disease known as Sjögren's syndrome is at the root of the dry mouth. The disease causes the body to attack the tear ducts and salivary glands, producing extreme cases of dry eyes and dry mouth. Ninety percent of sufferers are postmenopausal women, says Papas, who has been researching the disorder for more than 20 years.
In a normal mouth, teeth are continuously bathed in saliva, which contains antimicrobial compounds that stave off decay. So whether xerostomia stems from prescription drug use or from Sjögren's, dry mouth leaves teeth at increased risk for decay, especially at the roots. Additionally, Papas says, patients with dry mouth tend to eat more sweets—hard candy, sugared soda or ice cream—to sooth the discomfort associated with xerostomia. To combat this vicious cycle, Papas has been researching ways to prevent cavities and root decay in people suffering from dry mouth, as well as ways to restore damaged teeth.
The Issue of Access
In one of her earliest research projects, Papas screened more than 2,000 residents of 30 Massachusetts nursing homes. She found a "huge, unmet need." Her resulting report, a position paper for the Commonwealth of Massachusetts, led to legislation requiring oral exams for nursing home residents at least once a year.
But 25 years later, that great need still exists among Massachusetts' elderly. Access to dental care is a major issue for older Americans. About 5 percent of the elderly live in long-term care settings, and another 5 to 10 percent of the population is homebound. People who may have had dental insurance through their employers typically lose it when they retire, and Medicare does not cover dental care at all. Too often, senior citizens forego dental visits because of the expense.
"We focus a lot of our public health efforts on children, which is important, but we need to focus equally on the older population," says Catherine Hayes, D87, chair of the dental school's department of public health and community service. "At least children are in the system—they are in schools, and we do school-based programs. Whereas the elders, they may be living alone. They just may not be in the system at all."
Older adults are also more likely to suffer medical consequences from poor oral health, and vice versa. Diabetics, for example, are more prone to gum disease and abscesses. And although the causal relationship is not known, there is a reported link between periodontal disease and cardiovascular disease.
"One mistake that people make—and it's an understandable mistake—is that if they don't have teeth, they don't think they need to go to the dentist," Hayes says. Yet the golden years are exactly when patients are at increased risk for serious illnesses. Oral cancer has a very low survival rate relative to other types of cancer, specifically because it is often diagnosed at the later stages. Yet if it is detected early enough, it is very treatable.
Senior citizens often see their physician more than their dentist because they do have medical coverage under Medicare. "What would be wonderful to see is the same coverage for dental care," Hayes says. But there is little promise of that in the near future. With health issues like HIV and cancer already competing for available resources, "oral health falls to the bottom of the priority list," she says. "What other disease do you know that you can completely prevent? If you do adequate home care and make regular visits to your dentist, you could be disease-free." (continued)
Story by Julie Flaherty and Jacqueline Mitchell, senior health sciences writers in Tufts Office of Publications
Photos by Laura Barisonzi
This story ran online on Mar. 23, 2009. It originally appeared in the Winter 2009 issue of Tufts Dental Medicine.