March 2001 Aging TrendsThe Aging Trendsdeveloped withsupport from theNational Institute CENTERS FOR DISEASE CONTROL AND PREVENTIONNational Center for Health Statistics The Oral Health of Older America ID: 388158
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OverviewOral health is an important and often overlooked compo-nent of an older persons general health and well-being. Inthe words of former Surgeon General C. Everett Koop:You are not healthy without good oral health. Oral healthcan affect general health in very direct ways. Oin speaking, chewing, and swallowing. These problems canalso be a complication of certain medications used to treatsystemic diseases. In addition, the treatment of systemicThere are also associations between oral health and generalhealth and well-being. For example, the loss of self-esteemis associated with loss of teeth and untreated disease (cariesand periodontal diseases) as well as the economic burden ofinsurance programsfor the elderly. Although oral health problems are not usuallydeaths each year, and more than half of these deaths occuramong persons 65 years of age and older.This report focuses on the oral health needs of older adults.Using data from several national surveys, this report de-scribes the current status of oral health among the elderly,how these older Americans use dental health services, andwhat the future holds for the oral health of older Ameri-cans. Some of the findings reported are from newly tabu-lated data, and some are from published data.More older people arethan ever before. However,there are sharp differencesby race and socioeconomicNearly one-third of per-sons 65 years of age andolder have untreated den-Oral cancer increases withage. Mortality rates fromoral cancer are higherSlightly more than one-halfof noninstitutionalizedpersons 65 years of age andvisit in the past year. Thedental visits varied by race,Only 22 percent of olderpersons were covered byprivate dental insurancein 1995; most elderly den-tal expenses were paid outByClemencia M. Vargas, D.D.S., Ph.D.Ellen A. Kramarow, Ph.D.Janet A. Yellowitz, D.M.D., M.P.H. The Oral Health of Older Americans March 2001 Aging TrendsThe Aging Trendsdeveloped withsupport from theNational Institute CENTERS FOR DISEASE CONTROL AND PREVENTIONNational Center for Health Statistics The Oral Health of Older Americans Vargas CM, Macek MD,Marcus SE. Sociodemographiccorrelates of tooth pain amongadults: United States, 1989.Pain. 85:87-92, 2000.This new series of reports features information to help monitor the health ofOlder Americans can expect to live longer than ever before. Under existing conditions, womenwho live to age 65 can expect to live about 19 years longer, men about 16 years longer. Whetherthe added years at the end of the life cycle are healthy, enjoyable, and productive depends, in part,upon preventing and controlling a number of chronic diseases and conditions.This report is one in a series undertaken by the National Center for Health Statistics, with sup-port from the National Institute on Aging, to help meet the challenge of extending and improv-ing life. By monitoring the health of the elderly, using information compiled from a variety of sources,we hope to help focus research on the most effective ways to use resources and craft health policy.Answering this question requires examining how oral health affects an older persons quality oflife, as well as looking at the diseases that are related to oral health. How oral health affects quality of lifeOral health problems can hinder a persons ability to be free of pain and discomfort, to maintaina satisfying and nutritious diet, and to enjoy interpersonal relationships and a positive self-image.Overall, oral health problems are more frequently found in an older adult population for whomother health problems are often a priority. Oral pain is a sign of an advanced problem in a tooth or in the gingival (gum) tis-dissipate with time, professional attention is needed to effectively manageNational data indicate that 7 percent of adults 65 years and older reported having tooth pain atleast twice during the past 6 months. Older adults who belonged to racial/ethnic minorities orwho had a low level of education were more likelyto report dental pain than older adults who werewhite or better educated. Older men and olderwomen showed no difference in their likelihoodDifficulty eating Oral health problems, whetherfrom missing teeth, ill-fitting dentures, cavities,gum disease, or infection, can cause difficulty eat-ing and can force people to adjust the quality, con-sistency, and balance of their diet. For example, Percent of persons 70 years of age and olderwho have trouble biting or chewing by educa-tional level, 1995Source: National Health Interview Survey, SecondYears of Education The Oral Health of Older Americanstend to eat fewer raw vegetables, salads, and fresh fruits than people who have their own naturalteeth. To date, however, available data do not show that these changes result in a diet of poornutritional quality. Edentulism can have obvious negative esthetic and functional(speech, chewing/eating) consequences. In 1993 one-third of noninstitutionalized adults 65Although there was no difference in the proportion of men and women who had lost all of theirteeth, there were large differences in the prevalence of edentulism by socioeconomic status. Per-sons with family incomes below the poverty line were almost twice as likely to be edentulous aspersons with family incomes at or above the poverty line. Similarly, edentulism was higher among In 1995-97, 52 percent of nursing home residents 75years of age and older were edentulous.The prevalence of total tooth loss also varied byState, ranging from 14 percent in Hawaii and 16percent in Oregon and California to 48 percent inWest Virginia and 44 percent in Kentucky. As a result of a more preventive approach towardprofession, the proportion of older adults whoUse of dental prostheses Quality dental prosthe-ses (dentures) can help persons who have lost someor all of their natural teeth improve their quality of life by restoring lost function and esthetics.Overall in 1988-94, 92 percent of the edentulous noninstitutionalized adults 65 years of age andolder had both an upper and a lower denture. However, in this group, 24 percent of black per-sons and 19 percent of Hispanic persons did not usually use their denture(s). Among elderlyhad both dentures; however, 18 percent did not usually use them.Multiple medications Because chronic diseases are so prevalent among older adults, many takemultiple prescriptions and over-the-counter medications. It is not unusual for at least one of theseFor example, antihistamines, diuretics, antipsychotics, and antidepressants can reduce salivaryflow. This can result in dry mouth, one of the most common side effects of both prescription andover-the-counter medications. Having a dry mouth can cause difficulty chewing, speaking, andswallowing. It also increases the risk of developing cavities and soft tissue problems. Dry mouthmay also decrease the ability to wear dentures. Prevalence of edentulism (total tooth loss)among persons 65 years of age and olderby ageSource: National Health Interview Survey, 1983,1993.Percent of persons Krall E, Hayes C, Garcia R.How dentition status and Kramarow E, Lentzner H,Rooks R, Weeks J, Saydah S.Health and aging chartbook.Health United States, 1999.Hyattsville, MD: NationalCenter for Health Statistics. Centers for Disease Controland Prevention. Total toothgreater than or equal to 65years -- selected states,1995-1997. MMWR. 48(10): 0%20% 60% The Oral Health of Older Americans Brown L, Brunelle JA,Kingman A. Periodontal statusin the United States, 1988-91:prevalence, extent, and demo-graphic variation. Journal ofDental Research. 75 (SpecIs):672-683, 1996. Page RC. Periodontal dis-evaluation of current informa-tion. Gerodontology. 1:63-70, U.S. Department of Healthand Human Services. OralHealth in America: A report ofthe Surgeon General - Execu-tive summary. Rockville, MD:U.S. Department of Healthand Human Services, NationalInstitute of Dental and Cranio-facial Research, NationalInstitutes of Health, 2000. Ries LAG, Eisner MP,Kosary CL, Hankey BF, MillerBA, Clegg L, Edwards BK(eds). SEER Cancer StatisticsReview, 1973-1997, NationalCancer Institute. Bethesda,Dental caries Dental cavities (caries), an infection of the teeth, represent another physiologicalburden, especially important for those whose systems are already weakened by diseases and aging.In 1988-94 nearly one-third of adults 65 years of age and older with natural teeth had untreateddental cavities in either the crown or the root of their teeth.Decay untreated by a dentist usually getsworse, resulting in pain and the potentialloss of teeth. Dental caries is one of theAlthough the prevalence of dental caries hasdeclined in the U.S. overall, declines havenot occurred among the most socially dis-advantaged groups of older adults. Thepersons with untreated caries increased between 1971-74 and 1988-94.Periodontal diseases Periodontal diseases (gum diseases) are infections of the supporting struc-tures of the teeth. When not treated, periodontal diseases can result in the loss of teeth. Theprevalence of periodontal diseases increases with age, from 6 percent among persons 25-34 yearsto 41 percent among those 65 years and older. This increase is not necessarily due to older persons being more susceptible to periodontal dis-eases, but rather to the consequences of these diseases (i.e., bone loss and gingival recession),which accumulate over time and are thus more evident in the elderly. Preventing periodontaldiseases is particularly relevant because recent studies have shown a possible association betweenthese diseases and diabetes and cardiovascular diseases, which are major causes of death among Oral cancer, which includeslip, oral cavity, and pharynx cancer, is ofparticular concern for persons 65 years ofage and older because they are 7 times more In 1997,result of oral cancer. More older adultsdied from oral cancer than from skinAlthough the occurrence of new cases(incidence) of oral cancer is slightly 1971-74 1988-94White28%23% Poor3339 Nonpoor2823Black42%47% Poor4050 Nonpoor4144 Percent of persons with untreated dental caries amongpersons 65-74 years of age by race and poverty statusSurveys. 65 years of age and older by sex and race, 1993-97Note: Rates are age adjusted to the 1970 U.S. standard population.Source: Ries LAG, Eisner MP, Kosary CL, et al. 2000. Total Male FemaleAll races446827White456928Black406521 Total Male FemaleAll races14219White14209Black17309 Dentate Edentulous All PersonsTotal70%18%54% Non-Hispanic White741857 Non-Hispanic Black461738 Hispanic582245 Less than 12 years521639 12 years751857 More than 12 years822976 The Oral Health of Older Americansblack adults, mortality from oral cancer is substantially higher among black men than amongAs with other cancers, survival improves when the cancer is diagnosed at an early stage rather thanat a later, more advanced stage. Because patients with an early stage of oral cancer rarely have painviding a comprehensive oral cancer examination. One possible explanation of the higher mor-tality from oral candental and medical services.Visiting a dentist is the most basic use of dental care services. Whether elderly persons get neededdental care is closely related to whether they have dental insurance.Dental visits allows for a comprehensive evaluation ofteeth, gums, and soft tissues, and forprevention, early detection, and treat-ment of oral health problems. It is alsoan opportunity for the dental profes-sional to review home care practices. Avisit in the previous year is consideredthe standard measure of appropriate uti-lization of dental care, independent ofthe presence or absence of teeth.For edentulous persons, a dental visitwill include a comprehensive evaluationof soft tissues as well as an evaluationand possible adjustment of prostheses. In1997, edentulous persons were much less likely to report having visited the dentist in the previ-ous year than were dentate persons (persons with their natural teeth). When asked how often theywent to the dentist, 75 percent of edentulous persons selected when needed, compared with 37In general, socioeconomic characteristics played a significant role in who received dental care.Overall, persons with more than a high school education were twice as likely to have visited thedentist in the past year than were persons with less than a high school education. Non-Hispanicwhites were also much more likely to have visited a dentist than were racial/ethnic minorities.Percent of persons 65 years of age and older who hada dental visit in the past year by race and educationallevel, 1997Note: Dentate persons have at least one natural tooth. Edentulouspersons have lost all their natural teeth.Source: National Health Interview Survey. Yellowitz JA. The Oralof Oral Cancer, The DentistsRole in Diagnosis, ManagementRehabilitation, and Prevention.Quintessence Books, Quintes-sence Publishing Company, Inc.Illinois. 2000. The Oral Health of Older Americans Isman R, Isman B. OralHealth America white paper:Access to oral health services inthe United States 1997 andbeyond. Chicago, IL: OralHealth America. 1997. Manski RJ, Moeller JF, MaasWR. Dental services: use,expenditures, and sources ofpayment, 1987. Journal of theAmerican Dental Association.Dental Insurance Dental insurance is an important predictor of dental care utilization. Be-cause dental insurance is usually acquired as part of a job benefit package, most persons lose theirdental insurance coverage when they retire. In some states, Medicaid provides limited coveragefor routine dental care for low income and disabled elderly persons. Medicare, on the other hand,does not cover routine dental care for older adults, but provides a few, very limited services con-sidered to be medically necessary.With only 22 percent of the adults 65 years andolder covered by private dental insurance in 1995,most dental care expenses for the elderly were paidout of pocket. Only 10 percent of dental expendi-tures were paid by private insurance, and 79 per-cent were paid out of pocket. What does the future hold for the oralThe trend in improved oral health status among persons 65 years of age and older is expected tocontinue as the new cohorts of older persons continue to be better educated, more affluent, andmore likely to keep their natural teeth. This positive change in oral health status shows that oraldiseases and tooth loss are not inevitable with aging, and that teeth can be expected to last inHowever, the fact that the coming generations of elderly are maintaining their teeth poses a chal-lenge for satisfying their dental care needs. As more people keep their teeth, more will be at riskfor dental diseases and will need more preventive, restorative, and periodontal services.Unfortunately, financing dental care for older persons is particularly difficult compared withother age groups, in part, because there are no Federal or State dental insurance programs thatcover routine dental services, and only 22 percent of older persons are covered by private den-tal insurance. Consequently, dental care is unreachable for many older persons living on afixed income. Yet adequate oral health care is important for all older adults, as it is for otherage groups.Another challenge arises in providing dental care for older persons because their care is oftenmore complex than dental care for younger adults. This complexity comes from the manymon oral health problems, are cumulative, older persons often endure the consequences of theiroral health experience from earlier years, such as missing teeth, large fillings, and the loss of toothsupport. These problems can be complicated by their decreased ability to care for their oralhealth. The elderly may also have multiple physical and psychological ailments that affect theirtreatment and require the dentist to have good medical knowledge and management skills. Percent of persons 65 years of age and olderwith private dental insurance by povertySource: National Health Interview Survey. PoorNear Poor The Oral Health of Older AmericansFurthermore, there is noticeable social inequality in the oral health of older adults. Older personswho live below the poverty line were almost 3 times as likely to report unmet dental needs as thosewho live at or above the poverty line (11 and 4 percent, respectively). Persons from lower nomic groups are also more likely to report having untreated cavities. The greater need for den-tal care among older persons at low socioeconomic levels is coupled with their lower level of pri-vate insurance coverage, which leaves this group at a significant disadvantage compared withthose at a higher socioeconomic level.tists and the proportion of dentists relative to the population are expected to decline. The de-cline in the dentist-to-population ratio will particularly affect the elderly because they are thefastest growing segment of the population and because their special needs will require specializeddental skills. Optimally, the elderly should receive care from specialists in geriatric dentistry orgeneral dentists with a good understanding of the medical, pharmacologic, and cognitive changesConclusionDuring the past 50 years, the oral health and use of dental services among older adults haveimproved. Although this trend is expected to continue as the population of older adults growsincreasingly maintains their natural teeth, continued improvement will also be dependent onaccess to appropriate dental care. Cohen RA, Bloom B,Simpson G, and Parsons PE.Access to health care. Part 3:Older adults. National Centerfor Health Statistics. VitalHealth Stat. 10(198), 1997. National Center for HealthStatistics, Health, UnitedStates, 2000 with AdolescentHealth Chartbook, Hyattsville,Maryland. Table 81, 2000. U.S. Department of Healthand Human Services. OralHealth in America: A report ofthe Surgeon General. Rockville,MD: U.S. Department ofHealth and Human Services,National Institute of Dentaland Craniofacial Research,National Institutes of Health, Ibid. The Oral Health of Older AmericansSome of the information in this reportcomes from surveys conducted by theNational Center for Health Statistics. Theseare the National Health Interview Survey,the Second Supplement on Aging (a surveyof respondents 70 years and older), the Firstand Third National Health and NutritionExamination Surveys, and the NationalNursing Home Survey.The National Health Interview Survey andthe Supplement on Aging are householdinterview surveys, while the National Healthand Nutrition Examination Survey is anexamination survey. They are surveys of thenoninstitutionalized population. The Na-tional Nursing Home Survey collects dataon patients from knowledgeable staff of thenursing home and from patient records.A limitation of this report is that mostsurveys do not cover the institutionalizedpopulation. Therefore, nationally represen-tative data on the oral health status anddental care utilization of the entire popula-tion 65 years and older are rare. Althoughonly 5 percent of the overall population 65years of age and older are instituthese persons are more likely thanhave serious oral health problems and theseases. In addition, long-term care residentsare less likely to have access to comprehen-sive dental care. The National NuHome Survey, conducted by NCHS, cosome oral health data. However, this surveydoes not include examinmation on dental care utilization.Suggested CitationVargas CM, Kramarow EA, Yellowitz JA. The Oral Health of Older Americans. Aging Trends; No.3. Hyattsville, Maryland:National Center for Health Statistics. 2001.