For several months now, our SUNSTAR CONVERSATIONS PRO series – dedicated to health care professionals – has seen experts discussing about oral health challenges such as caries and periodontal disease prevention, behavioral change, dentin hypersensitivity, from pregnancy to adulthood (re-watch here). In September, Prof. Dr. Martin Schimmel and Prof. Dr. Georgios Tsakos conversed on the oral challenges of the aging population. Getting older is accompanied with increasing physical limitations and gradual decline in body function. In the oral health domain, this is known as “oral frailty”, a concept that impacts on general health, wellbeing, and quality of life and whose prevention helps the patients to extend their healthy lifespan. Our experts aimed for unveiling this relatively novel construct. Read on below what was said in essence.
Frailty, Oral Frailty and Oral Hypofunction
There is not one simple definition of “Frailty”. The most used definition dates back to 20 years ago from Fried et al. and evokes a clinical syndrome of older adults where there are three or more symptoms from a list including unintentional weight loss, feeling exhausted, feeling very weak, low hand strength and grip, walking with a slow speed and having low physical activity. It is a very physical phenotype of frailty, but the definition can also include cognitive elements and even environmental aspects. As a dentist who treats elderly people and geriatric patients, Dr. Schimmel saw this concept of “Frailty” entering dentistry from the geriatrician side. A patient who is frail from a medical point of view will be weak and will probably be dependent on care. This frailty then has an impact on oral health: on the ability to clean the teeth, to prepare a healthy meal and so on. Frailty is a quite prevalent condition of older adulthood with more than 10 percent of the old adult population suffering from it.
Oral health is linked to healthy aging, from a physiological, functional point of view but also from a SOCIAL, cognitive and environmental one.
The concept of “Oral Frailty” is quite novel and comes from Japan where dentists are historically more involved in not only caring about teeth and oral diseases but also about oral function. A position paper published in 2018 by the Japanese Society of Gerodontology in the Journal of Gerodontology defines the concept of “oral frailty” as a pre-stage in the concept of “oral hypofunction”, i.e. a decrease of oral function due to gum diseases, caries and others, decreased occlusal force and sarcopenia of the chewing muscles. The condition was included in the Japanese healthcare system with certain thresholds for specific parameters like decrease of tongue function and pressure, lip function, occlusal force, masticatory and swallowing function, and poor oral hygiene and dryness. For Dr. Tsakos, “We’re talking with the same terminology, but the concepts of “Frailty” and “Oral Frailty” are not exactly the same. From a public health perspective while it is quite important to look at the functional aspects around the mouth, it’s also very relevant to see how the mouth fits within the broader picture of frailty and healthy aging.” This makes us think about how oral health links to the overall frailty because it also consists of cognitive aspects, environmental aspects and not only the physiological and functional aspects. Oral health is affected by the overall frailty but, in return, also affects it. More than that, it is about how to maintain oral health when you are frail and how an important part it is for a healthy aging. It is a clinical challenge and a public health challenge as well.
WHO resolution and the decade of healthy aging
The World Health Organization (WHO) has called the next decade until 2030 “the decade of healthy aging”. The reasons are of course the demographic transition but also the epidemiological transition in oral health with a high-need, older population. Healthy aging is about how to maintain a good level of health and oral health but also how to keep the social roles intact and a good quality of life until the very end.
The traditional care model will not be able to cope with the aging societies. Aging people constitute an important group of the population that cannot just be treated as per usual. Curricula in the dental schools and practicing dentists also need to be updated, to care for that population.
The global strategy from the WHO resolution on oral health considers a life course approach, aging populations and putting the mouth back into the body. The opportunity lies in acknowledging this earlier, before people become old and have problems, to have a good oral health throughout life and good behavioral patterns. Dentists need to address the issue that patients become older, and workload will probably be very much concentrated in the elderly patients in the coming years. Statistics from Japan show that the prevalence of caries increases with age while the prevalence of periodontal disease remains the same over the lifetime. But then, starting at age 60-70, the complaint about loss of chewing ability rockets. Addressing this functional issue is becoming critical, as patients will very likely end up losing weight due to multiple factors related to oral frailty such as the inability to eat, gum disease or pain in the mouth. Dentists need to become “more medical” to address the full picture of the patient and especially in frail patients and to collaborate even more with medical doctors.
“There is a real need, and we need to be aware that in our elderly patients, there is much more than drill and fill or taking a tooth out… We need to have the full picture of the patients, be it polypharmacy, multimorbidity, the logistic aspects like how they come into our practice, can they really go twice a year to the dental hygienist, how to organize this on an individual level…need of New care models adapted to the aging society is raising. There is an opportunity here for dentistry to become closer to medicine”, says Dr. Schimmel.
Need of new care models adapted to the aging society is raising.
Initiatives to adapt the care to older patients
There is a consensus that we should brush our teeth perfectly twice a day but the barriers to apply this are too high in the people living in nursing homes. Indeed, research coming from the University of Cologne from Dr. Barber and Dr. Noack, for example, shows that we need to find new concepts on oral hygiene that are applicable in terms of workforce.
Dentistry from the past would say “if you can’t clean the teeth, why not just take all the teeth out and put full dentures in”. But edentulism is the final stage of oral impairment. Dentures are prosthesis and no proper function and sensation whatsoever can be achieved without teeth, even with implants. Dr. Tsakos even tends to tell his students that edentulism is actually more or less the equivalent of mortality in the oral health field. Recent epidemiological trends show that there is hardly any prevalence of edentulousness, which is a reason for celebration but also a responsibility to maintain these teeth healthy, and recent research also tackles now how an adequate oral health can be ensured in homebound people or people dependent on homecare.
Different countries try different methods, but things are indeed happening. In Switzerland for example, the idea of having a specially trained dental assistant, not necessarily a dental hygienist, going once a week to brush the teeth of these patients in nursing homes showed a significant positive impact on their oral health. In the UK, while oral health of vulnerable adults in care homes was neglected, guidelines are being implemented to engage more stakeholders and define programs to take care of oral hygiene.
Overall, we need to learn from these initiatives to establish best practices at a global level, in all countries, but emphasis should be put before people even enter care homes, as longitudinal data with 5- to 13-year follow-up show that oral health markers are also very reliable indicators of frailty further down the line.
What can dentists do about oral frailty?
Prevention of caries late in life remains a priority to maintain oral function.
If teeth are lost, it is already a bit too late but when it happens, function can still be regained, better with dental implants than with removable prosthesis.
There is an emergence of devices for oral training, for example little rubbers of different hardness to train the chewing muscles or increase coordination of the facial structures but they are still in their early stages.
There are also new devices coming from Japan to measure tongue pressure for example: it is a little balloon the tongue presses against the palate. Chewing efficiency can also be assessed by measuring glucose extraction from chewing gum jelly. These are very good predictors for frailty later in life.
Although the number of remaining teeth is important, their health status is also important for oral function and quality of life. Indeed, the global burden of disease study shows that the most prevalent oral condition worldwide is still caries, in the permanent dentition not in the primary one. Caries is not a disease of childhood but is prevalent until late in life and root caries is a major issue. And the evidence shows how much caries impacts on quality of life. Prevention is however possible with diet, oral hygiene, high fluoride toothpaste or even silver diamine fluoride that has proven quite effective in studies, although the agent is not available in all countries and tends to make teeth black.
All in all, facing patients who are frail, dentists can’t just leave them be and need to know how to manage them with a caring approach.
Early prevention to put people on a good trajectory when they are young and prevention of tooth loss throughout lifetime will allow a functional dentition without removable denture in the older adults and a higher quality of life for the later stages of life.
If you want to listen to the experts, you can watch the entire webinar here.
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See you all there!