Section 3B

Periodontal Implications: Older Adults

James D. Beck*

*Department of Dental Ecology, University of North Carolina, Chapel Hill, North Carolina

Question Set INTRODUCTION

1. Identify indications / contraindications for
treatment modalities, including: biologic fac-
tors, psychological factors, and medication
factors which can affect treatment planning
and the impact of institutionalization on treat-
ment planning.
2. Review the relative strengths and weak-
nesses of each.
3. Identify therapeutic endpoints.
4. Do therapeutic endpoints differ in vari-
ous age groups?
This review had two general objectives.
The first objective was to summarize back-
ground information describing the demo-
graphics, medical/physical/health status,
and oral status of older adults along with
implications of those characteristics for
treating older patients. This part of the re-
view was not an evidence-based approach
and the conclusions were based on current
consensus of the relationships described

5. Are there risk factors in the older popu- and their importance. The second objective
lation which not in the younger was to critically review the literature on per-
are present
population? iodontal disease in older adults with empha-
6. Does periodontal disease pathogenesis sis on age as one of the risk factors for
differ in older patients? Periodontitis (the epidemiology of periodon-
tal diseases is reviewed in Section 2A). This
section does include an evidence-based ap-
proach to arriving at conclusions; i.e., meta-
analysis.
The literature review process was com-
posed of several steps. First, Medline
searches were conducted and recent issues
of appropriate journals were searched by
hand. While the searches focused on articles
published during the last 10 years, earlier
articles were included if they were judged to
be important in describing the setting in
which the more recent articles were con-
ducted. In addition, tables of contents for
upcoming issues of four journals were sup-
plied by the Academy and those contents
were reviewed. Then, appropriate references
contained in the articles being reviewed were
added to the list. In all, 367 articles and
three textbooks on aging were reviewed and
Ann Periodontol 1996;1:322-357. 115 reported here. Review articles, which
 Review: Periodontal Implications: Older Adults
were useful for obtaining references and for
determining how others organized the ma-
terial, were not used in the review on aging
and periodontal disease as they did not con-
tain original research. However, review arti-
cles were used as part of the background
section on aging. Articles that did not di-
rectly address the relationship of age to per-
iodontal diseases were then eliminated,
along with articles that did not include older
adults. The exception to including only ar-
ticles addressing age was for the section on
treatment outcomes, which contained ran-
domized clinical trials testing the efficacy of
systemic and topical medications in the
treatment of periodontal diseases. This part
of the search was aided by Dr. Phillip Hujoel,
who provided a data base that he had com-
piled as part of an effort to ascertain the po-
tential for conducting meta-analyses for
evaluating periodontal treatments. This data
base was used to review randomized clinical
trials (RCTs) and to generate additional ar-
ticles for review. While no trials tested the
efficacy of a drug within an age group, the
articles were reviewed to determine if there
were studies that could be used in a meta-
analysis to determine outcomes by age
group. This approach would entail the au-
thors of the articles providing additional
data by age group in order to conduct a
meta-analysis for treatment outcomes by
age. Details of this process are described
later.
The major sections of this review include
a background that describes aging in gen-
eral, the prevalence and incidence of perio-
dontal diseases by age in community-dwell-
ers, the prevalence of periodontal disease in
institutionalized people, aging and risk fac-
tors for periodontal disease, and aging and
periodontal outcomes. Evidence tables are
presented only for studies involving perio-
dontal diseases. Thus, the organization of
this review (prevalence, incidence, risk fac-
tors, outcomes) results in each evidence ta-
ble containing studies of similar design. For
example, Table 1 presents studies on the
prevalence of periodontal disease by age,
which means that all studies in that table
must be cross-sectional designs. When this
occurs, the studies are not listed by impor-
323
tance of the study (based on study design).
Instead, they are listed by year of publica-
tion in order to provide the reader with a his-
torical perspective of research in that area.
The next section presents important
background information on the demograph-
ics, medical/physical/health status, oral
status of older adults. In addition, implica-
tions of these characteristics for treating
older patients is presented. This section is
referenced, but is not based on evidence ta-
bles.
The review follows the outline below:
I. Background
A. Demographics
B. Oral Health Status
C. Health and Illness
D. Implications for Treatment Planning
II. Aging and Periodontal Diseases
A. Prevalence in community-dwellers
B. Incidence
III. Prevalence in Institutionalized Individu-
als
IV. Aging and Periodontal Risk Factors
A. Risk Factors from Incidence and Clin-
ical Studies
B. Do Factors Differ for Different Age
Groups?
V. Aging and Periodontal Outcomes
A. Plaque and Gingival Inflammation
B. Preventive and Surgical Outcomes
C. Systemic and Topical Medication
Outcomes
VI. Alternative Outcomes
VII. State of Knowledge
BACKGROUND
When discussing that segment of the pop-
ulation that composes the oldest 15% to
20% of the population, a number of terms
can be used, such as, the elderly, elders,
aged, geriatric, seniors, or older adults.
"Older adults" is used in this review simply
because the author prefers that term to the
others. Because age distributions differ
among countries as well as cultural expec-
tations for people of various ages, the age at
which someone becomes an older adult can
vary along with their role expectations and
society's attitude toward them. Historically,
Vol. 1, No. 1, November 1996
324 Beck

Table 1. Prevalence of periodontal disease measures related to age (cross-sectional studies by publication date)
Author
Date of Publication
Country
(Date of study
if known) Methodology Sample Results Comments
Burt et al.81 PI used and OHI-S, Data from N HAN ES I % edentulous ranged from Response rate of 74%.
1985 which has a debris and survey of a nationally 3.2 in 25-34 group to 46.1 (n=11,338). PI no longer
USA a calculus index representative sample in 65-74 group. % with no used. Where excellent oral
(1971-1974) of 20,749 people disease decreased from hygiene is maintained, age
57.8 to 36.3; % with gingi- does not seem to be an im-
vitis decreased from 28.2 portant variable in perio-
to 13.1; % with pockets in- dontal disease status
creased from 14.0 to 50.6
Abdellatif & Burt9 PI used and OHI-S, Data from N HAN ES I Logistic model indicated Response rate of 74%. (n
USA which has a debris and survey of a nationally OHI and age had almost =
11,338). PI no longer
1987 a calculus index. Esti- representative sample same predictive power as used. Where excellent oral
(1971-1974) mated incidence of Per- of 20,749 people model with other covaria- hygiene is maintained, age
iodontitis from tes. OHI was strongest with does not seem to be an im-
age-specific prevalence OR of 20.5 with OR for age portant variable in perio-
rates of 1.2. Estimated inci- dontal disease status.
dences show OHI ac- Estimated incidences is
counts for at least 88% of technique not used often in
Periodontitis in all age dentistry
groups
Miller et al.8 AL measures at buccal Working adults from AL > 2 mm. For adults, Use of partial mouth and
=

1987 and mesio-buccal sitesmulti-stage random mean AL increased with sampling frame may result
USA in randomly selected sample of U.S. work- age from 2.08 in 18-19 in underestimation of AL
(1985-1986) quadrants. Manual places. Seniors from at- year olds to 3.04 in those
probe rounded down to tendee of senior aged 60-64. % sites with
next whole mm centers AL increased from 11.17 to
51.07 by age. For seniors,
mean AL increased from
3.13 in 65-69 group to 3.71
in > 80 group. % sites in-
creased from 52.05 to
59.99

Schurch et al.85 PN, Gl, supral- and sub- 180 people from 6 cities Tooth loss, mean PH, Gl in- Response rate 58.9% (n =

1988 gingival calculus, PD, in Canton of Berne and crease with age 206). PD and CAL not re-
Switzerland and AL on mesio-buc- 170 from 17 villages or ported by age
cal, buccal, disto-buccal small towns sampled
and lingual surfaces. randomly stratifying on
PD and AL in mm and sex and 5 age groups
width of keratinized tis-
sue from premolar to
premolar in each jaw
Ship & Wolff9 CAL calculated from re- 55 healthy, local, com- 60-89 group had 17.4 teeth Shows patterns similar to
1988 cession and PD on 6 munity-dwelling Cauca- compared to about 27 in other prevalence studies in
USA surfaces of Ramfjord sian, non-smokers, no other groups. 60-89 group a group that is healthy,
(1987) teeth. Super- and sub- medications. had greater AL, recession, does not smoke, or take
gingival calculus col- Age 22-39, n 18; =
and plaque than other medications. Sample size
lected on same sites age 40-59, n 18; groups. They also had is small in each age group
=

age 60-90, n 19 =
more bleeding sites and and lack of power to detect
calculus than the youngest some differences may be a
group problem
AL attachment loss.
= CEJ cemento-enamel junction.
= PD :
probing depth,
BOP bleeding on probing.
=
Gl gingival index.
=
PI =
periodontal index,
CA calculus.
=
OR odds ratio.
=
Pll =
plaque index.
CAL clinical attachment level.
=
OHI-S oral hygiene index, simplified.
= =
socio-economic status.

Annals of Periodontology
 Review: Periodontal Implications: Older Adults 325

Table 1. Continued
Author
Date of Publication
Country
(Date of study
if known) Methodology Sample Results Comments
Papapanou et al.' Series of 16 periapical 531 dentate people re-
Mean bone level increased Pronounced bone loss ex-
1988 and 4 bite-wing using ferred to oral radiology
from 1.4 in 25-29 year olds isted in only 11% of sub-
(1974-1976) standardized parallel
were selected from to 5.4 in those 75. Regres- jects; was absent below
technique. 1,980 people by ran- sion analysis showed age
Alveolar age 35; and 27% of those
bone level =
distancedom selection using and n teeth were signifi- age > 70. Individual tooth
between CEJ and most birthdate until 50 people cantly related to mean site data were not cor-
had been sampled in 11 bone level. Age also was
coronal along root sur- rected for non-independent
face with periodontal age groups related to bone level at the observations
ligament space normal individual site, controlling
width for sex, number teeth, jaw,
mesial-distal site, and tooth
type
Beck et al. CAL calculated from re- Random sample of 811 Number of teeth decrease Number of teeth not in-
1990 cession and PD meas- community people in 5 by age group from 21.3 to cluded in models as they
USA ures on all teeth at N.C. counties age > 65 15.7. Age not related to ex- may be an alternative
(1988) buccal and mesio-buc- stratified by race and tent or severity of CAL. Age measure of serious CAL.
cal sites rounded down urban-rural status. Age not significant risk indicator Exams performed by 5 cal-
to next whole mm. Se- groups were 65-69, 70- in multivariate model for ibrated dentists
rious AL defined as > 4 74, 75-79, > 80 classifying people into se-
sites with AL of > 5 mm rious CAL versus not seri-
+ 1 of those sites with ous CAL
PD of > 4 mm
Hunt et al,1 CAL calculated from re- Random sample of 520 3 age groups (70-74, 75- 4 calibrated examiners.
1990 cession and PD meas- people age > 67 in 2 ru- 79, > 80). For buccal sites, 425 of 520 available for
USA ures on all teeth at ral Iowa counties at extent of sites with CAL > 1986 exam, response rate
(1986) buccal and mesio-buc- baseline in 1983. Exam 1mm increased with age of 82% for exam
cal sites rounded down protocol modified in (48% to 60%) and mean
to next whole mm 1986 follow-up, so 1986 CAL in sites with >1mm
exam used as baseline LA increased with age (1.7
to 2.2). The same meas-
ures in mesio-buccal sites
did not show an increase
with age

Papapanou et al.87 Measures made on all 511 subjects selected Number of teeth, gingivitis, The 10 people with the
1991 buccal, lingual, and ap- from community clinics. PD, and CAL increased least CAL in each age
Sweden proximal surfaces for 3 age cohorts (born with age for all subjects group (best group) were
(1976-1977) 28 teeth. Gingivitis=
2 1949-60, 1932-48, be- and for the "best" group. compared to the age group
or 3 score on Le and fore 1931). All had > 12 However, "best" group had as a whole. Bone loss
Silness, PD and CAL teeth and willing to be in much less at each age measured by standardized
recorded to nearest mm 5-year preventive den- group. Alveolar bone loss radiographs.
tistry program for the "best" group did not
increase with age Age-related alterations in
periodontium may not in-
evitably be manifested as
loss of CAL or alveolar
bone

Vol. 1, No. 1, November 1996

326 Beck

Table 1. Continued
Author
Date of Publication
Country
(Date of study
if known) Methodology Sample Results Comments
Locker and Leake88 AL calculated from re- Baseline from ongoing Age significant for
was 3 calibrated examiners.
1993 cession and PD on 2 study of community- mean regression in-
AL in Telephone interview on
Canada sites/tooth using pres- dwellers age > 50 in cluding smoking, educa- 3,033 people and 907
(1977-1978) sure-sensitive probe at Ontario. Random-digit- tion, and regular prevent agreed to exam. The 907
20g dialing. Phone interview visits. Also significant for were similar to the 3,033 in
followed by exam in model including n of teeth, age and gender
home smoking, decayed root sur-
faces, last dental visit. OR
for severe disease (highest
20% AL) not severe, were
above 3 for those age > 75
compared to <75
Sereno et al.' Recession calculated 225 regular attenders at Proportion of subjects with Study design was longitu-
1994 by subtracting PD from 12 clinics. There was a recession increased with dinal, but most results pre-
Sweden CAL at buccal aspect of baseline, 5-year, and age, there were different sented as 3 cross-
(1982-1983) each tooth. When CAL 12-year follow-up. Sub- patterns of recession in dif- sectional studies. 58% of
exceeded PD by > 1 jects had high standard ferent age groups with mo- variance of buccal reces-
mm recession was of oral hygiene meas- lar and premolar recession sion was explained by ap-
present. CAL and PD ured by plaque and in 18-41 year olds and proximal CAL, approximal
assessed to nearest BOP more even distribution in bone level, gingivitis score
mm older group at buccal sites, and whole
mouth plaque score
Fox et al.20 PD and CAL at buccal, A 2-stage, stratified, In this group aged > 70, Response rate <50%. Au-
1994 mesio-buccal, disto-lin- cluster sample of New age was not significantly thors found substantial per-
USA gual, and "deepest site" England elders. 1,151 associated with periodontal iodontal disease in this
(1989-1990) on all teeth of 2,598 eligible com- measures group. Speculate age dif-
pleted interview and ferences in other studies
exam may be cohort differences
in retention of teeth, oral
health habits, dental care
use

Grossi et al.1 Calibrated examiners 1,426 subjects recruited Age most strongly associ- Baseline exam of a longi-
1995 assessed supragingival using combination of ated with CAL with OR tudinal study. Wide age
USA plaque, subgingival cal- random selection, con- from 1.7 for 35-44 up to 9.0 group included with part of
culus, PD, and CAL. In- venience patients from for 65-74. Diabetes, smok- the sample randomized
terview assessed dem- dental school, and re- ing, P. gingivalis, B. forsy-
ographics, systemic dis- sponse to ads. Broad thus were associated with
eases, stress, coping age range, had teeth, CAL. Controlling for gen-
and behaviors. Plaque and no need for antibi- der, SES, income, educa-
samples for microbes otic coverage tion, and oral hygiene
and serum samples for status, the above factors
antibody levels still were significant
AL attachment loss.
=
CEJ cemento-enamel junction.
=
PD =
probing depth.
BOP bleeding on probing.
=
Gl =
gingival index. PI =
periodontal index.
CA calculus.
=
OR odds ratio.
=
Pll =
plaque index.
CAL clinical attachment level.
=
OHI-S oral hygiene index, simplified.
=
SES =
socio-economic status.

Annals of Periodontology
 Review: Periodontal Implications: Older Adults 327

Table 1. Continued
Author
Date of Publication
Country
(Date of study
if known) Methodology Sample Results Comments
Grossi et al.94 Calibrated examiners 1,361 subjects ages 25- In 10-year age groups Baseline exam of a longi-
1995 assessed supragingival 74 recruited using com- starting at age 25, bone tudinal study. Wide age
USA plaque, subgingival cal- bination of random loss categories (healthy, group included with part of
culus, PD, and CAL. Ra- selection, convenience, low, moderate, severe) are the sample randomized
diographic bone loss as- patients from dental inversely related to age
sessed along long axis school, and response to group. In ordinal logistic
of tooth from CEJ to al- ads. Broad age range, model of the 4 categories
veolar crest using com- had teeth, and no need of bone loss (above), OR
puter imaging and soft- for antibiotic coverage for age group 35-44 was
ware package. Plaque 2.6 and increased for age
samples for 8 organisms group up to 24.0 for age
65-74, controlling for kid-
ney disease, education,
allergy, gender, smoking,
race, and P. gingivalis and
B. forsythus

AL attachment loss.
=
CEJ cemento-enamel junction.
=
PD =
probing depth.
BOP bleeding on probing.
= Gl gingival index.
=
PI =
periodontal index.
CA calculus.
= OR =
odds ratio. Pll =
plaque index.
CAL clinical attachment level.
=
OHI-S oral hygiene index, simplified.
= SES =
socio-economic status.

the chronologic age of someone defined as
an older adult involved the age at which
someone should be eligible to retire, which
was chosen to be at age 65. As lifespan has
increased, age 65 as the lower limit is looked
older adults are a challenge to dental prac-
titioners. Thus, if a younger adult presents
with problems similar to those commonly
seen in older adults, those younger adults
can be considered to be "biologically old"

upon as being arbitrary and having less
meaning, yet still is commonly used. In fact,
gerontologists have found it useful to specify
a group called the "oldest old," those age 85
and older, as a group of special interest.
Thus, older adults, as used in this review
primarily refers to the lower age limit used
in most studies, age 65, but is used in a flex-
ible manner to also include studies with a
lower age limit, such as 50, or higher, such
as 80. This flexibility in the definition of
older adult recognizes the changing social
definition of who is old and recognizes that,
for dentists treating patients, it is important
to also consider a person's "biologic age."
Dentists do not need to pay special attention
to older adults simply because they are
chronologically old. It is because chronologic
and require similar types of treatment plan
considerations. Consequently the term older
adult, as used in this review, refers primarily
to a group of people who are age 65 and older
(but may be younger) and adults of any age
who are functionally, medically, and men-
tally complex.
Demographic changes around the world
along with new information on how older
adults use dental services and the types of
dental conditions they present have man-
dated that the dental profession consider de-
livery of services to that segment of society
in more detail. As part of these considera-
tions, it is essential that providers under-
stand the diagnostic and treatment planning
challenges presented by older adults who
are more likely to arrive at the dental office

age is associated with physical changes, in- with age-associated physical changes, in di-
creased prevalences of physical and mental minished physical and mental health, and
conditions, decreased levels of function, and with multiple medications. Special chal-
increased consumption of medications that lenges are presented by that growing seg-

Vol. 1, No. 1, November 1996

328
ment of older adults who are homebound or
reside in institutions. This section summa-
rizes some of that information.
Demographics
Distribution of older adults in the popula-
tion. Industrialized countries contain ap-
proximately 25% of the world's population
(estimated to be 5 billion in 1990) and the
age distribution within those countries is
different from the age distribution in more
rural societies. In industrialized societies
15% to 18% of the population is above age
60 compared to only 5% to 8% in more rural
societies. However, it has been projected
that in urbanizing regions in China, Africa,
and South America 10% to 12% of the pop-
ulations will be older adults by 2025.1
Examples of industrialized countries are
taken from Scandinavia and the United
States. In Scandinavian countries, the pop-
ulation has been aging for more than 100
years. In 1870 the percent of the population
over age 65 ranged from 4% to 6%, while in
1988 the figures ranged from 13% to 18%.
In addition to an increasing percentage of
each birth cohort reaching age 75 over the
last 30 years, life expectancy has been in-
creasing for older adults. Males and females
at age 75 can be expected to live an addi-
tional 7.5 to 8.2 years and 9.6 to 10.6 years
respectively in Scandinavian countries. Two
additional trends are important. The major-
ity of older adults are women and that pro-
portion has been increasing over time and
the greatest increases have been and are
projected to continue to be in the oldest-old
(those aged 85 and over).2
The United States has experienced similar
trends. While the proportion of those over
age 65 has increased dramatically, even
greater increases are expected in the next
century due to the cohort known as the post-
World War II "baby boom." For example, in
1900 the proportions of the population over
age 65 and over age 85 were 4% and 0.2%
respectively. Over the next 90 years, those
proportions had risen to 12.6% and 1.3%.
By the year 2050, they are expected to rise
to 22.9% and 5.1%.3 Again, most older
adults in the U.S. are women and that pro-
Annals of Periodontology
Beck
portion is expected to rise. In 1960 there
were 86 men per 100 women aged 64 to 74
and 67 men per 100 women aged 85+. By
the year 2000, those figures are expected to
be 76 men per 100 women and 39 men per
100 women respectively.4
Thus clinicians should be seeing a greater
proportion of older adults in their practices
and they should expect that proportion to be
increasing. The ever-increasing majority of
those older adults should be women and the
proportion of people over age 85 should also
be increasing.
Use of dental services. Use of dental serv-
ice patterns differ for those living indepen-
dently in the community and those who are
institutionalized or homebound with the lat-
ter using services much less frequently.
One reason that dentistry had not con-
cerned itself with older adults in the past
was that previous generations of older
adults had used dental services much less
frequently than younger age groups. In
1982, Ettinger and Beck5 reviewed the social
and dental histories of two different cohorts
of older adults, one born in 1900 and one
born in 1915, and concluded that the dental
profession should be preparing for new gen-
erations of older adults who are more likely
to have teeth and use dental services. Pop-
ulation trends appear to be consistent with
this conclusion. Gift and Newman6 using
data from the 1989 National Health Inter-
view Survey showed that since 1964 the per-
cent of people with a dental visit in the last
year has been increasing steadily and the
percent of older adults with a dental visit has
been increasing at an even faster rate. Con-
sequently in 1989, a little over 60% of den-
tate older adults visited the dentist in the
last year, while about 65% of dentate
younger age groups visited a dentist during
the same time period. A representative study
of New England elders over the age of 70 re-
ported only slightly lower utilization rates
(51% in the last year).7 However, certain seg-
ments of older adults have lower utilization
rates. Less than 15% of edentulous older
adults have visited the dentist in the past
year, a trend that is supported by a national
study of employed adults and seniors at-
tending senior centers.8 In addition, health
 Review: Periodontal
status and physical limitations affect utili-
zation patterns.6 Over 50% of older adults
who self-assess as being in excellent health
used dental services in the past year, while
about 33% who judged themselves to be in
fair or poor health had a visit. Similar figures
are reported for those who report no limita-
tions in their activities compared to those
who report being unable to do basic activi-
ties.
Thus the use of dental services by com-
munity dwelling older adults has increased to
a rate that is very similar to younger groups
for those older adults who have teeth (trends
in edentulism rates are covered in the section
on Tooth Loss). In addition, the U.S. Preven-
tive Health Task Force Guidelines for Preven-
tive Services for older adults indicate that
access to dental services for older adults is
important and recommends regular dental
age groups.9 The Canadian Task
visits for all
Force on Periodic Examination is more spe-
cific in recommending annual dental exami-
nations for people over age 65.10
Institutionalized and homebound. Only
about 5% of the population over the age of
65 resides in long-term care facilities and
another 5% to 10% are considered to be
homebound.41112 Dolan and Atchison13 state
that the dental utilization patterns of nurs-
ing home residents are poorly described.
Few studies report utilization rates, but
those that do indicate that about 20% of res-
idents have been to the dentist in the last
year and that the mean time since the last
visit was almost 5 years. Use patterns for the
homebound essentially are unknown.
Oral Health Status
Although periodontal disease is the focus
of this review, a general description of the
patterns of tooth loss and caries is useful to
help put the dental utilization and periodon-
tal disease patterns of older adults in per-
spective.
Tooth loss. Edentulism rates in older
adults in many countries have been high, of-
ten affecting between 50% to 80% of older
adults, while rates in the U.S. have been
somewhat lower.14 However, there is sub-
stantial evidence the edentulism rates have
Implications: Older Adults 329
been dropping in many western, industrali-
zed countries, including the U.S.214"16 Gen-
erally, current rates of edentulism in people
over age 65 are approximately 40%, ranging
from 30% in the 65 to 69 age group to almost
50% in the 80+ age group.2'7 814 Most recent
studies indicate that dentate older adults on
average have 19 to 20 teeth remaining.817 20
Longitudinal studies of tooth loss indicate
that most older adults do not lose any teeth
over a given year and those who do lose teeth
lose only one or two.1819-21 Further, those
studies indicate that both caries and perio-
dontal disease are almost equally responsi-
ble for tooth loss,1819 21 although periodontal
disease seemed to be the main reason for to-
tal tooth loss.15
With edentulism on the wane, it would ap-
pear the future cohorts of older adults will
have teeth, so we might expect even higher
proportions using dental services. While fu-
ture cohorts will have more teeth that are at
risk for periodontal disease, it is not clear
whether we should expect more disease as
some studies have found that the more teeth
older people have, the less likely they are to
have disease (healthy survivor effect).22
Finally, since periodontal disease is re-
lated to tooth loss, we should remember that
missing teeth may represent some under-es-
timation of periodontal disease.
Caries. Historically, the relationship be-
tween caries and age was thought to be
characterized by increasing caries rates
through childhood and then a decrease in
late adolescence or young adulthood. By the
time people were age 35 to 40, concerns
about caries were replaced by concerns
about periodontal diseases as the prime oral
problem. Studies conducted over the last 20
years indicate that coronal caries does occur
frequently in older adults and that root car-
ies also becomes a problem. Most studies
have found that the overall incidence of root
caries is lower than the incidence of coronal
caries. However, like coronal caries, not all
root surfaces are at risk for root caries in
that they are not exposed. When attack rates
are calculated (number of new lesions per
100 surfaces at risk for disease), root caries
attack rates can be substantial and exceed
attack rates for coronal caries.811'23 34
Vol. 1, No. 1, November 1996
330
Thus, older adults do experience caries, it
isresponsible for a substantial portion of the
tooth loss in older adults, and these adults
are likely to be seeking dental services be-
cause of perceived restorative needs.28
Health and Illness
The review to this point has indicated that
there will be more older adults, that they
have a substantial number of oral conditions
needing treatment, and that they are almost
as likely to use dental services as any other
age group of comparable socioeconomic
status. This section summarizes the type of
physical, medical, and mental conditions
that they are likely to bring with them into
the dental office that make diagnosis, treat-
ment planning and treatment a challenge.
Changes associated with aging. Most
studies of aging changes have been cross-
sectional in nature and generally have char-
acterized aging as a time of loss and decline.
Some longitudinal studies have come to
some different conclusions and other stud-
ies have indicated that changes considered
to be normal, because they happened to
most people, were probably due to patho-
logic conditions. Thus, there is debate about
which, if any, changes are "normal aging
changes." While this academic debate is in-
teresting, the dentist probably needs to be
more concerned with the type of changes
that are likely to accompany a dental patient
coming for treatment. Common age-related
changes are summarized with two caveats:
1) that while these biologic changes are com-
monly seen, they may not be "normal aging
changes;" and 2) that there is wide variation
in these biologic changes in individuals of
the same chronological age. Thus, the den-
tist should not plan treatment for patients
based on chronological age, but instead
should evaluate the patient's biologic age,
based on the patient's medical, mental, and
functional status. There are a number of
physiologic changes associated with ag-
ing.412
1. Blood pressure regulation: Decreased
vascular and cardiac ventricular compliance
and decreased baroreflex sensitivity reduce
cardiovascular compensatory ability. In-
Annals of Periodontology
Beck
creases in sympathetic nervous system
activity and decreases in
end-organ respon-
siveness impair compensation for hypoten-
sive stresses and drugs. Blood pressure
control is affected by changes in renal so-
dium conservation. These changes impair
the body's ability to maintain normal blood
pressure homeostasis. Since elevations in
blood pressure may impair blood pressure
homeostatic capacity, older hypertensive pa-
tients may be at greatest risk for hypotensive
events (including orthostatic hypotension).
Temperature regulation Many healthy
people fail to demonstrate vasocon-
-
older
striction on cooling. The threshold for dis-
criminating temperature differences in-
creases, diminishing the ability to sense cold
and the sweating response is reduced.
Higher core body temperatures are needed
to induce sweating and vasodilatation is de-
layed.
2. Body fluid regulation. Older people
have increasing difficulty both retaining so-
dium when needed and excreting excess wa-
ter.
3. Barrier defenses. The mucosal surfaces
help prevent infection by trapping organisms
in secreted mucus and removing them by
ciliary transport. Age-related changes may
impair these functions. Increased coloniza-
tion by Gram-negative bacilli has been
reported in the Oropharynx, peristaltic ure-
thral areas, and vaginal introitus. Certain
skin lesions predisposing to infection are
more common in older adults, for example,
bullous disease, pressure sores, and
trauma.
4. Physical and mechanical defenses.
There is a disturbance with swallowing with
advanced age. This predisposes people to as-
piration, a common cause of pneumonia in
older people. This problem is compounded
by an age-related slowing of the mucociliary
apparatus and the cough mechanism is de-
creased, further reducing the ability to elim-
inate organisms. The collapse of small
airways and loss of elasticity in the respira-
tory system increase the risk of infection.
Urinary tract changes that alter host defense
include: urinary alterations in osmolality,
pH, and high urea concentration; decreased
prostatic fluid with reduced bactericidal ac-
 Review: Periodontal
tivity; diminished flushing mechanism of the
bladder; and potential for obstruction to
urine flow.
Specific immune responses The humoral
immune response is impaired in older adults
-
predominately due to changes in helper T-
lymphocytes. Specific antibody responses to
foreign antigens, such as tetanus toxoid or
pneumococcal Polysaccharide are impaired
while antigenic production and the number
of B cell appear unchanged. Production of
other immunogloubins, such as auto-anti-
bodies increases.
5. Physical activity. Aging produces sev-
eral changes in the ability to acquire and de-
liver oxygen to tissues. Because of these
changes, the physical work capacity of the
average 70-year old is only half that of a 20-
year-old. Although the decrease is progres-
sive over this age span, the rate of loss
accelerates in the mid 50s. Physical exercise
can do much to slow these losses.
There also are physical changes with ag-
ing.412 There is a trend toward decreased
height (stooped posture secondary to in-
creased kyphosis); decreased weight; in-
creased fat-to-lean-body mass ratio; and
decreased total body water. The skin shows
increased wrinkling and atrophy of the
sweat glands. The cardiovascular system ex-
hibits elongation and tortuosity and intimal
thickening of arteries, increased fibrosis of
media of arteries, and a decreased rate of
cardiac hypertrophy. These changes lead to
decreased cardiac output; a decreased heart
rate response to stress; and decreased com-
pliance of peripheral blood vessels. The kid-
ney exhibits decreased Creatinine clearance;
decreased renal blood flow; and decreased
maximum urine osmolality. The eyes tend to
have decreased accommodation to light
changes and decreased acuity, color sensi-
tivity, and depth perception. The hearing ap-
paratus tends to undergo degeneration of
ossicles, increased obstruction of the eusta-
chian tube, atrophy of coclear hair cells, and
loss of auditory neurons. These changes re-
sult in decreased perception in frequencies
and decreased pitch discrimination. Changes
in the brain and nervous system tend to re-
sult in increased motor response time;
slower psychomotor performance; decreased
Implications: Older Adults 331
complex learning; decreased hours of sleep;
and decreased hours of REM sleep. Changes
in the endocrine system tend to be increased
insulin, norepinephrine, parathormone, and
Vasopressin.
Johnson et al.35 have summarized aging
changes in the periodontium. The summary
evidence reviewed indicates that while nu-
merous morphological, biochemical, meta-
bolic, and immunologic changes can be
observed in the periodontium with aging, it
is not clear that these changes play a signif-
icant role in susceptibility to or progression
of periodontal disease. It seems that in the
absence of disease, the clinical changes in
the periodontal support apparatus attribut-
able to aging alone are therapeutically insig-
nificant.
While there are a number of age-associ-
ated changes that occur, it may be helpful
for the practitioner to think about those
changes in the following terms: changes re-
sult in gradual loss and often begin in early
adulthood; thanks to the redundancy of
most organ systems the decrement does not
become functionally significant until loss is
fairly extensive; most organ systems lose
function at roughly 1% a year beginning at
age 30; most older people will have normal
resting laboratory values, the real issue is
how the organ (person) functions when
stressed (examples: older adults may have
normal blood sugar levels at rest, but cannot
handle a glucose load within normal para-
meters of young people; thus, 2-hour post-
prandial glucose levels may be less helpful
than fasting blood levels to detect and man-
age diabetes, or older patients with normal
resting pulse may be unable to achieve ad-
equate increase in cardiac output with ex-
ercise) .
Medical conditions. It is well-known that
older adults are more likely to arrive at the
dental office with medical conditions in
addition to their dental problems. Medical
conditions and medications related to perio-
dontal diseases are specifically reviewed in
Section 3A and only are briefly mentioned
here, because of their implications for treat-
ment planning and patient management.
The most common causes of death in older
adults are heart diseases, cancer, stroke,
Vol. 1, No. 1, November 1996
332
influenza and pneumonia, diabetes, and su-
icide (usually related to depression), indicat-
ing that people with these conditions are
likely to be seen in the dental office.2436 In
fact, it has been reported in some studies
that heart disease is the most prevalent
problem seen in Periodontitis patients37,38
and other studies report heart disease to be
the second most prevalent problem after
drug allergies.39 41 It also is important to note
that these medical problems occur with fre-
quency at all adult ages, but are more fre-
quent in older patients.39 But this is not the
complete picture, because people suffer from
chronic conditions that often do not cause
death. The most common chronic conditions
in order include: arthritis, hypertension,
hearing impairment, heart disease, cata-
racts, orthopedic impairment, chronic si-
nusitis, diabetes, visual impairment, and
varicose veins.3 To make the situation more
complicated, older adults often suffer from
multiple conditions. Conditions that com-
monly co-exist include: congestive heart fail-
ure, depression, dementia, chronic renal
failure, angina pectoris, Osteoarthritis, os-
teoporosis, gait disorder, urinary inconti-
nence, vascular insufficiency, constipation,
diabetes, sensory deficits, sleep disturbance,
adverse drug reactions, and anemia.4 To
complicate the situation even further, dis-
eases can have atypical presentations in
older adults. The most common kind of atyp-
ical presentation is the appearance of one or
more nonspecific problems, usually involv-
ing functional loss, such as stopping eating
or drinking; falling; urinary incontinence;
dizziness; acute confusion; new onset or
worsening of previously mild dementia;
weight loss; or failure to thrive. In addition,
one disease can be masked by another, or
that the usual signs and symptoms of the
disease are not present and the disease is
discovered accidentally.4 Thus, medical con-
ditions of older dental patients must always
be carefully evaluated and considered in
dental treatment planning. In evaluating
medical conditions, the dentist should keep
in mind the results of a study comparing the
medical histories given by older patients to
information gained from the patients' phy-
sicians.42 There was only a 50% agreement
Annals of Periodontology
Beck
on diagnoses between the patient history
and the physician, which increased to a 77%
agreement if they were compared only on
general system responses. The patient and
the physician both reported conditions the
other did not report.
Use of medications. It is not surprising
that the large number of chronic conditions
in older adults leads to their use of multiple
medications. Fortunately, the use of medi-
cations that impact on dental diseases or
dental treatment has been of concern and
there are some organized sources of infor-
mation available.
Early work indicated that in 1980, of the
more than 160 million prescriptions written,
47% could have direct effects on the oral
cavity (e.g., may cause xerostomia or tissue
hyperplasia) and an additional 34% may
have indirect effects (e.g., present contrain-
dications or precautions for certain dental
procedures).11 Lewis, et al.43 building on ear-
lier work of Baker et al. ,44 classified prescrip-
tion medications taken by a representative
sample of 4,100 community-dwelling older
adults into categories of potential oral ef-
fects. They reported the following percent-
ages of people using medications with
implications for dental providers: xeros-
tomic, 56%; abnormal hemostasis, 52%; soft
tissue reactions, 23%; taste changes, 11%;
altered host resistance, 9%; gingival over-
growth, 5%; and movement disorders, 2.4%.
Thus, older adults also are likely to present
with medications that can impact on oral
conditions or can affect the type of treatment
or manner in which they should receive den-
tal treatment.
In addition, dentists may prescribe medi-
cations that can affect their patient's other
conditions. For example, periodontists may
wish to prescribe nonsteroidal anti-inflam-
matory agents (NSAIDs) for their patients.
Yet, NSAIDs can increase blood pressure in
patients with hypertension; can cause acute
renal failure in patients with chronic renal
impairment; can cause gastrointestinal
hemorrhage in patients with peptic ulcer
disease; and confusion or delir-
can cause
ium in someolder adults.4 In addition to
standard sources for drug information, Mul-
ligan and Sobel45 present a useful review of
 Review: Periodontal
medications commonly used by the elderly
and their implications for dental practition-
ers.
Physical disability. Dentists also must
consider any physical disabilities of their pa-
tients, including the ability to keep dental
appointments without assistance and the
ability to maintain an independent lifestyle.
A recent study of dental conditions in a rep-
resentative sample of community-dwelling
New England elders looked at measures of
physical disability.20 They found that 15% of
the sample had difficulty or were unable to
transfer out of bed; that 9% had problems
getting outside; that 8% had trouble walk-
ing; that 11% 7%, and 6% respectively had
, Osteoporosis appears to occur more fre-
difficulty bathing, dressing, or using the toi-
let. In this study, physical disability was sig-
nificantly associated with higher rates of
edentulism and more dental caries, but not
more periodontal disease. The lack of a sig-
nificant association with periodontal disease
may have been due to a definition of 1+ teeth
with a pocket > 4 mm, which included 63%
of this population. Another large community
study reported disabilities that may more di-
rectly influence a patient's ability to perform
oral hygiene procedures or receive dental
treatment.46 For people over the age of 65,
approximately 10% of men and 17% of
women had difficulty extending their arms
above their shoulders; approximately 11% of
men and 15% of women could not sit for one
or more hours; and approximately 20% of
men and women had difficulty holding small
objects. These types of difficulties must be
taken into account when evaluating a pa-
tient's ability for self-care.
Osteoporosis. Osteoporosis is the most
common metabolic disease. It is character-
ized by low bone mass (osteopenia) and de-
terioration of the skeletal tissue, affecting
both cortical and trabecular bone, which
leads to increased risk of fracture.47 Osteo-
porosis then can be defined as a reduction
in bone mass with associated pain, defor-
mity or pathologic fracture.48 Osteopenia is
a reduction in bone mass to below a prede-
fined level (usually bone mineral content
more than 2 standard deviations below the
mean bone mineral content of young normal
adults of the same gender).49 Osteoporosis is
Implications: Older Adults 333
classified as primary and secondary. Pri-
mary osteoporosis includes post-meno-
pausal (Type I), age-related (Type II), and
idiopathic osteoporosis. Secondary osteopo-
rosis is caused by an idenifiable agent or dis-
ease.50 The rate of bone loss is approximately
2 times greater in women than in men. Post-
menopausal osteoporosis is a heterogeneous
disorder that begins after natural or surgical
menopause and leasd to fractures within 15
to 20 years from cessation of ovarian func-
tion.51 In the Western world more than one-
third of the female population over age 65
suffers from signs and symptoms of osteo-
porotic fractures.52
quently in people over age 50; in females; in
people with a family history of osteoporosis;
in Caucasians; in people with prolonged im-
mobility; in people with no exposure to sun-
light; in females with small bones; in people
with excessive alcohol consumption, tobacco
smoking, or coffee drinking; in people using
certain medications such as chronic use of
corticosteriods; and in people with certain
medical disorders, such as diabetes, hyper-
thyrodism, and rheumatoid arthritis.47'53
Since the loss of alveolar bone is a result
of periodontal disease, osteoporosis has
been suspected to be related to periodontal
disease. However, this relationship has been
difficult to establish as many studies have
had inadequate sample sizes and have not
controlled for confounders (factors common
to both periodontal disease and osteopo-
rosis), such as age, smoking, diabetes, and
medications. A number of studies have
found associations between osteoporosis in
skeletal bone and in mandibular bone.54 58
However, some studies investigating the
relationship between osteoporosis and peri-
odontal disease have found the two condi-
tions to be related,54-59 61 while other studies
have not.82'63
Osteoporosis occurs much more fre-
quently in older adults and appears to be re-
lated to periodontal status. In addition,
osteoporosis and periodontal disease may
share some common antecedent character-
istics. Consequently, while osteoporosis in
older adults should be a definite concern for
periodontists, much additional information
Vol. 1, No. 1, November 1996
334
is needed. The relationship between the
bone density of the mandible and the skel-
etal bones needs to be more firmly estab-
lished. Pd.sk factors for osteopenia in the
mandible need to be identified and the role
that osteopenia plays in the establishment of
periodontal disease needs clarification.
Alzheimers's disease. Alzheimer's disease
is a progressive, age-related, chronic cogni-
tive dysfunction that can be divided into
three stages.64 It has been estimated that
this illness accounts for almost two-thirds of
all cases of dementia. There are no clinical
diagnostic tests for Alzheimer's disease and
a diagnosis is made only after eliminating all
other causes of dementia.65
Dental treatment modifications will de-
pend on the stage of the disease. The key
feature of stage 1 is memory loss, however,
it is important to differentiate Alzheimer's
disease from simple forgetfulness. Disorien-
tation with respect to time and space, lack
of spontaneity, and errors in judgment also
may characterize this stage. In addition, per-
sonality changes occur in which there is a
flattening or blunting of affect. Changes are
gradual in the early stages of disease (a
characteristic that differentiates Alzheimer's
from dementia) and frequently it is an out-
side observer that notices something differ-
ent. In the second stage, cognitive function
continues to decline and memory loss in-
creases, involving both short and long-term
memory. The patient may have sleep distur-
bances with wandering at night; inability to
write; perform basic arithmetic; and carry
out purposeful movements. Mirror sign, a
failure to recognize oneself in a mirror, may
occur. In the third stage, there is complete
disorientation, behavior problems, gait dis-
turbances, and seizures.64 65 Psychotic symp-
toms including delusions, hallucinations,
and paranoia also may appear. There is a
general decreased level of consciousness, in-
continence, and an inability to maintain
normal muscle control.66 The most common
treatable disease that can mimic Alzheimer's
disease is depression. Some features that
distinguish the illness as depression are
poor appetite, weight loss, insomnia, early
morning awakenings, and rapid onset of
symptoms.
Annals of Periodontology
Beck
Several reviews of oral health in Alzhei-
mer's patients indicate that gingival and
dental health do deteriorate and that pre-
vention at the early stages are recommended
to reduce the need for treatment at later
stages.166567 Chapman and Shaw68 summa-
rize some of the management considerations
with Alzheimer's patients. There is little al-
teration in delivery of care at the early stages
when the patient is cooperative, except that
procedures take longer because of the need
for repeated reassurance and explanation.
When communicating, the dentist should
use simple words, short sentences, speak
slowly and clearly, ask only one question at
a time, and repeat it exactly if necessary.
Later in the illness the patient will be less
cooperative and a secured, mouth prop may
be needed to keep the mouth open. The pa-
tient usually will be restless and may need
the gentle restraint of the care giver placing
a hand on the shoulder. Pre-operative se-
dation may be useful, for example, haloper-
idol. In the more advanced stages, a general
anesthetic usually will be needed, even for
simple procedures.
Homebound and institutionalized adults.
The often quoted statistic that 5% of the peo-
ple over the age of 65 years are in nursing
homes is misleading. In fact, less than 2% of
people aged 65 to 74 are in nursing homes,
while the rate rises to 7% for those aged 75
to 84 and rises further to 20% for those aged
85 and over. 36 Given the dramatic increases
projected for the proportion of the popula-
tion 85 and older and assuming that our
patterns of nursing home care do not dra-
matically change, the dental profession
must prepare for the care of many more pa-
tients who reside in nursing homes.
There have been many surveys of the oral
status of nursing home residents. Berkey et
al.69 have conducted the most organized re-
view of those surveys. In general, nursing
home residents have much poorer oral
status than community-dwelling older adults,
with approximately 60% of those residing in
nursing homes having substantial periodon-
tal treatment needs. In addition, character-
istics of the nursing home itself have been
shown to be associated with oral health.
Larger homes,70 homes located in smaller
 Review: Periodontai
communities, and for-profit homes are asso-
ciated with poorer oral status.71 While almost
nothing is known about the oral status of
homebound elders, Strayer and Ibrahim72 re-
ported on dental treatment provided through
a homebound program treating 123 people.
They reported providing a combination of
periodontal/preventive treatment to 60% of
the people seen. It should be noted that a
higher percentage of nursing home and
homebound people may need treatment, but
are judged to be too frail to be treated.
Although all patients admitted to a nurs-
ing home must have a dental screening and
eventually a dental exam, before instituting
treatment, the dentist should understand
the types of people who are admitted to
nursing homes and how long they will be
there. There are two types of nursing home
patients, "short stayers" and "long stayers."12
Short stayers usually are in the nursing
home less than 6 months and are subdi-
vided into 2 groups, the terminally ill and
the rehabilitation patient. The terminally ill
primarily receive "hospice type" care and of-
ten are too ill for definitive dental treatment.
The short-term rehabilitation patients are
discharged from hospitals in order to recover
more fully and receive rehabilitation serv-
ices. Part of these rehabilitation services
could be dental care. The long stayers usu-
ally are in the nursing home longer than 6
months and about one-fourth of the resi-
dents are there for more than 2 years. This
group can be subdivided into 3 groups,
those that primarily are physically impaired
(severe arthritis, osteoporosis, heart dis-
ease), those that are cognitively impaired
(dementia, Alzheimer's disease), and those
that have both types of impairment. The
goals for dental treatment of these various
groups should consider the types of condi-
tions that brought them to the nursing home
and how long they are likely to be a resident.
Because of the severe problems that bring
residents to the nursing home and the prob-
lems inherent in institutional settings, nurs-
ing home residents may present additional
problems to the dentist. Limeback has re-
viewed the special problems of nursing
homes.73 Because of the clustering of pa-
tients, nosocomial respiratory infections can
Implications: Older Adults 335
be problem. One major source of aspirated
a
organisms implicated in bacterial pneumo-
nia in older adults are anaerobes, which are
present in patients with periodontai disease.
In fact, diagnosis of an anaerobic pneumo-
nia often can be made on the symptoms pre-
sented at the emergency room and because
of its frequency, it has been referred to as
"nursing home pneumonia."7475 In addition,
15% to 20% of sepsis cases have been linked
to a recent visit to the dentist during which
tissue manipulation and exposure of the
blood stream to organisms most likely oc-
curred.76
The cognitive and physical disabilities of
nursing home patients often prevent them
from providing their own oral self-care. In
these instances, nurses, or more often
nurses aides, must provide oral hygiene care
for these patients. Two recent studies have
evaluated ease of use and plaque removal
ability of oral hygiene devices when used by
a caregiver. In one study of 60 nursing home
residents who were given oral hygiene by
hired caregivers who used both a conven-
tional brush and a powered brush in a
crossover design. Both brushes reduced
plaque and gingival inflammation with the
powered brush having significantly greater
reductions and being preferred by the care-
givers.77 The second study tested four de-
vices, a disposable foam brush, a conventional
toothbrush, a manual curved toothbrush,
and an electrical toothbrush. Dental stu-
dents were the patients and one person was
selected as a non-professional care provider.
Results showed the foam brush to be least
effective, the conventional toothbrush to be
intermediately effective, and the curved
toothbrush and the mechanical toothbrush
to be most effective. The patients reported
that the curved toothbrush was the most
comfortable and the caregiver reported it
was the easiest to use.78
Informed Consent. Most clinicians are fa-
miliar with the criteria for informed consent;
that the dentist must provide appropriate
information about the proposed treatment
including the nature of the treatment, the
benefits and risks, and the alternatives to
treatment in language the patient can un-
derstand; that the patient must comprehend
Vol. 1, No. 1, November 1996
336
what he/she has been told; that there is no
deception; that the patient must be compe-
tent to give consent; and that the informed
consent process is the patient's decision.79
The competency issue is a special concern
for the older adult. The dentist should as-
sume that all older adult patients are com-
petent to participate in the decision-making
process and look for signs that they may not
be competent, rather than the reverse. Le-
gally incompetent patients should partici-
pate in decisions as they can and the legal
guardian must authorize all treatment. Of
greatest concern are the legally competent
patient with impaired decision-making abil-
ity. When decision making seems question-
able but the patient has retained legal
competence, the dentist should establish
how surrogate decisions should be made
and who should serve as proxy decision
maker.80 There is some controversy about
whether "do not resuscitate" orders estab-
lished in one setting (e.g., the nursing home)
should be portable to another setting, such
as the dental office. Dentists should become
familiar with the interpretation of such or-
ders in their locale.80
Implications for Treatment Planning
Since treatment planning is done specifi-
cally for each patient, it is difficult to make
specific recommendations for treatment
planning of older adults. However, some
general statements may be appropriate:
1. Avoid labeling patients by their chron-
ological age, instead think about patients
relative to their physiological or biological
age.
2. Do not forget that most older adults are
expected to live at least another 10 years.
3. The vast majority of older adults are
relatively healthy with some age-associated
changes.
4. Make sure you consider the implica-
tions of the age-associated aging changes
most frequently seen in older adults.
5. Keep in mind that the main challenges
community-dwelling, medically-
of treating
compromised older adults are to prevent
medical complications during or following
Annals of Periodontology
Beck
care and avoiding unwanted medication in-
teractions and effects.
6. Remember that the signs and symp-
toms of medical conditions often are ex-
pressed differently in the older adult and
thatthey often are expressed as a functional
loss,or as depression or confusion.
7. Do not assume that patients know or
can report all of their medical conditions.
8. Remain current on the oral effects of
medications and on the implications of those
medications for the types of treatment that
can be provided and under what conditions
that treatment can be provided.
9. Remember the implications of medica-
tions prescribed by dentists on systemic
conditions often present in older adults.
10. Evaluate the physical disabilities of
patients to see how they may impact on oral
self-care.
11. Do not forget that there are several
categories of nursing home patients and
those categories should influence the
amount and type of dental treatment being
planned.
12. Assume that nursing home patients
will have oral treatment needs, but that their
medical, physical, and mental conditions
may affect whether or not the need can be
treated.
13. Consider that nursing home patients
may be at high risk for sepsis and pneumo-
nia that may be related to oral conditions
and treatment.
14. Always remember that care of nursing
home patients also involves working with
care-givers and family.
15. Remember that early definitive and
preventive dental treatment of Alzheimer's
patients can prevent more difficult interven-
tions at later stages.
16. Remember that treatment of home-
bound elderly may mean the involvement of
care-givers.
17. Remember that there may be special
informed consent issues.
AGING AND PERIODONTAL
DISEASES
A review of the literature describing the
topic of aging and periodontal disease/ther-
 Review: Periodontal
apy produced over 300 possibly relevant ar-
ticles. Of the articles identified, the only
randomized, controlled trials involved stud-
ies that investigated the outcomes of thera-
peutic interventions, which did not report
results by age. Consequently, the majority
of information regarding the relationship
between periodontal diseases and chrono-
logical age comes from cross-sectional, ep-
idemiological studies, while some informa-
tion comes from baseline examinations
from clinical studies. More recently data
from population-based incidence studies
that described the relationship between
Periodontitis and chronological age have be-
come available along with longitudinal clin-
ical studies.
Prevalence in Community-Dwellers
(Table 1)
The prevalence of periodontal disease has
been shown to increase with chronological
age in a countless number of studies. Na-
tional U.S. data from the early 1970s which
used Russell's periodontal index (PI), a com-
posite measure of periodontal disease that
includes gingivitis, mild pocketing, and se-
vere loss of tooth support, showed that in
spite of increasing tooth loss in older ages,
the percent of people with gingivitis de-
creased with age and the percent of people
with mild and severe pockets increased with
age.81 Earlier studies82 84 using the same per-
iodontal measure (not shown in the evidence
table) had similar findings. More recent
studies, using disaggregated measures of
periodontal disease, such as the gingival in-
dex (GI), the plaque index (PI), clinical prob-
ing depths (PD), clinical attachment level
(CAL), and bone level, also have shown that
periodontal status worsens with age in the
general population8 85 90 and in systemically
healthy adults.91 Thus, there seems to be lit-
tle doubt that the prevalence of periodontal
disease increases with age and, in general,
we should expect to find more periodontal
disease in older adults. This information,
however, is of little use to practitioners who
must treat the periodontal conditions unless
it is clear whether it is becoming older that
is related to a worsening periodontium or
Implications: Older Adults 337
whether the worsening periodontium is re-
ally related to other characteristics that are
related both to becoming older and to peri-
odontal disease. In other words, is periodon-
tal disease age related or age associated? If
periodontal disease is age associated, the
periodontal disease-age association should
be diminished by other characteristics of the
people.
In a national sample of the U.S. popula-
tion, Abdellatif and Burt92 estimated inci-
dence of disease from prevalence data. They
show that oral hygiene (OHI index) was
much more strongly associated with perio-
dontal destruction than age and that OHI
accounts for 88% of the periodontal disease
in all age groups. This finding would support
the age-associated interpretation. Support-
ing the same interpretation are studies that
were restricted to older adults. These studies
all indicated that once a person becomes an
older adult (approximately age 60 to 70),
that age is not associated with the preva-
lence of disease or disease severity,17'2093
while other factors, such as dental visits,
presence of periodontal pathogens, educa-
tional level, financial status, and general
health conditions are related to periodontal
status. On the other hand, Papapanou et
al.86 showed that age was related to mean
bone level at the individual site controlling
for sex, number of teeth, jaw, mesial-distal
site, and tooth type. However, the site anal-
ysis did not include corrections for non-in-
dependent observations. In another study,
Papapanou et al.87 who made age-specific
comparisons of people with low levels of at-
tachment loss (best group) to the remainder
of the group, showed that attachment loss
increased with age for both the general
group and the best group. However, the best
group had much lower levels of attachment
loss, indicating that age-related alterations
in the periodontium may not be inevitable.
Locker and Leake88 also found that age was
significantly associated with attachment
level, controlling for number of teeth, smok-
ing, decayed root surfaces, and last dental
visit.Grossi et al.90 found that age was sig-
nificantly associated with attachment level,
even controlling for diabetes, smoking, Por-
phyromonas gingivalis, Bacteroides forsy-
Vol. 1, No. 1, November 1996
338
thus, gender, socioeconomic status (SES),
income, education, and oral hygiene status.
In another paper using the same sample,
Grossi et al.94 investigated the relationship
between alveolar bone loss and age using
four bone loss categories (healthy, low, mod-
erate, severe) and 10-year age groups start-
ing at age 25. They found that the older the
age group, the more likely they were to be in
the most serious bone loss categories. In an
ordinal logistic model of the 4 categories of
bone loss (above), the odds ratio for age
group 35 to 44 was 2.6 and increased for
each age group up to 24.0 for age 65 to 74,
controlling for kidney disease, education, al-
lergy, gender, smoking, race, and Porphyro-
monas gingivalis, and Bacteroidesforsythus.
Thus, the findings from prevalence studies
regarding the question of age-related versus
age-associated are mixed, even though most
of the current thinking is that the relation-
ship is age-associated.
It should be noted that cross-sectional
studies of periodontal disease are not well-
suited to answer questions that concern the
relationship between age and disease. This
occurs because clinical attachment level and
probing depth really are measures of accu-
mulated disease experience. Thus, older
people would be expected, in general, to
have had more disease experience. Incidence
data, which represent new disease and dis-
ease progression over a period of time, are
better suited to answer questions about dif-
ferential risk among age groups.
Incidence (Table 2)
The evidence to be addressed in this sec-
tion involves whether or not older people are
more likely to contract periodontal disease
or whether periodontal disease is more likely
to progress in older people. Eight incidence
studies conducted in Japan,95 97 Scandina-
via,9899 and the U.S.100 102 103 that followed
people for time periods ranging from 1 to 28
years and reported results by age are in-
cluded.
Two reports by Lindhe et al. on the same
population followed for 2 one-year periods
indicated that there was little overall change,
that most change occurred in a few people,
Annals of Periodontology
Beck
that mean scores masked individual differ-
ences, that 20% of people had loser sites
(sites that lost attachment) in both years,
and that loser sites rose from 33% in those
aged 20 to 29 to 62% in those aged 60 to
79 95,96 However, another report on 1-year
data from that same population found that
age was not significant when included in a
multivariate model that contain other base-
line clinical variables.97 The authors con-
cluded that the relationship with age to new
probing attachment loss appears to be due
to the relationship of age to baseline attach-
ment level. A similar pattern of findings was
found in a Swedish study that followed a
group over 10 years, using bone loss as an
outcome measure.98 The mean annual rate
of bone loss increased with age, but a mul-
tivariate analysis indicated that age was not
a significant factor when other characteris-
tics were considered. Two additional studies,
one using attachment level and one using
bone loss as the outcome measure, found
that younger individuals were more likely to
experience disease progression than older
individuals, but neither study considered
the relationship in a multivariate analy-
sis.99100 Brown et al.,101 studying clinical at-
tachment level over 18 months in people
aged 65 and older, found that in older
adults, age is not related to attachment loss.
A multivariate analysis confirmed the lack of
a relationship. On the other hand, Ismail et
al.,102 who conducted a follow-up study 28
years after baseline found a non-significant
trend showing that average attachment loss
was greater in older individuals. However,
age was found to be significant in a multi-
variate model. A clinical study by Grbic et
al.103 supports the Ismail et al. findings as
they found that patients over the age of 60
had higher incidence rates of clinical attach-
ment loss independent of other characteris-
tics. However, the authors correctly caution
that their results should not be generalized
beyond a patient population with active Per-
iodontitis who have at least 18 teeth.
The preponderance of current evidence in-
dicates that the relationship between age
and periodontal disease is age-associated,
rather than being a consequence of aging.
When higher incidence rates of periodontal
 Review: Periodontal Implications: Older Adults 339

Table 2. Incidence of peridontal disease measures according to age (cohort studies by publication date)
Author
Date of Publication
Country Length of Study
(Date of study if known) (in months) Methodology Sample Findings Comments
Albandar et al.( 24 3 periapical radio- 293 factory workers The rate of bone This was a site-
1986 graphs in each from Oslo volun- loss was higher in based analysis with
Norway jaw. Bone loss teered; 180 were age groups 33-45 no allowance for
was distance from examined at follow- (0.125 mm) and 46- non-independent
CEJ to alveolar up. Age was 18-68 57 (0.212 mm) than measures
crest. > 2 mm was at baseline the 58-68 age group
bone loss (0.135) when initial
level of bone loss
was held constant.
Periodontal break-
down increased rap-
idly between 33 and
56 years of age
Lindhe et al.95 Two; 12-month AL, PD, recession Random sample of Most subjects had lit- Examiners followed
1989 follow-ups measured at 6 319 20-79 year-old tle change in CAL same subjects. 57
Japan sites/tooth on all residents of Ushiku, and PD while a few of 319 missed a fol-
teeth Japan in longitudinal showed extensive low-up and not in
study examined at change. Any chang- analysis. Respon-
follow-up with no es in oldest age dents and non-re-
treatment group due to a very spondents similar
small number of sub- except for AL in
>
jects. Mean scores 20-29 age range
mask significant among non-respon-
changes in individu- dents
als
Lindhe et al.96 Two; 12-month AL, PD, recession Random sample of 40% (104) of 265 Examiners followed
1989 follow-ups measured at 6 319 20-79 year old subjects seen at all same subjects. 57
Japan sites/tooth on all residents of Ushiku, visits had loser sites of 319 missed a fol-
teeth Japan in longitudinal of >2mm of AL. low-up and not in
study examined at 33% of age 20-29 analysis. Respon-
follow-up with no up to 62% of age dents and non-re-
treatment 60-79. Older sub- spondents similar
jects more likely to except for >AL in
have more sites af- 20-29 age range in
fected. Only 20% non-responders
had loser sites in
both years and 70%
of loser sites were in
12% of subjects

Papapanou et al.98 120 At least 6 periapical 283 of 531 dentate The mean annual Same examiner for
1989 and 4 bite-wing people with radio- rate of bone loss all. Site analyses did
Sweden films obtained by graphic exams in was 0.07 mm in the not account for non-
(1985-1986) standardized paral- 1974-76 randomly 25 year group, independent meas-
lel technique. Alve- selected for new about 0.14 mm at ures
olar bone level =
exam. 201 re- ages 40-55 years
distance between sponded and films and 0.28 mm in the
CEJ and most co- were obtained from initially age 70 sub-
ronal along root dentists of 54 non- jects. Tooth loss
surface with perio- respondents also increased with
dontal ligament age and may result
space normal width in underestimation
of bone loss. In a
multivariate analy-
sis, age was not sig-
nificantly associated
with mean annual
rate of bone loss

AL =
attachment loss. Gl =
gingival index.
CAL =
clinical attachment level. MAL =
mean attachment loss.
CEJ =
cemento-enamel junction. PD =
probing depth.
Annals of Periodontology
340 Beck

Table 2. Continued
Author
Date of Publication
Country Length of Study
(Date of study if known) (in months) Methodology Sample Findings Comments
Ismail et al.102 336 One examiner in Baseline exam in AL increased with No statistically or
1990 1959 and 3 in 1959 of all commu- age group. Those clinically significant
USA 1987 who were nity-dwellers in Te- born 1945-54 had differences in those
(1959-1987) calibrated. Gingi- cumseh Ml. 690 AL 0.88mm, while
= in 80km radius and
vitis, calculus, mo- (86%) received den- those born 1900-24 those not. AL very
bility, PD, and AL tal exam. 1987 exam had 1.43 mm over low over 28 years in
using Ramfjord excluded people bom the 28 years. Differ- most people
methods. AL at 4 before 1900 and out ence between co-
sites per tooth of 80km radius of horts not significant.
town. 167 examined In logistic model
in 1987 with AL threshold at
2mm, birth cohort
was significant
Haffajee et al.' 12 CAL, PD, Random sample of
reces- Age group was pos- Examiners followed
1991 sion measured at 319 20-79 year-old itively related to > 1 same subjects. These
Japan 6 sites/tooth on all residents of Ushiku, sites of new AL of > findings may have
teeth Japan in longitudinal 3 mm (20-29 12% implications for other
=

study examined at up to >59 =

43%). age-related periodon-
follow-up with no The relationship of tal disease findings
treatment. 271 were age to new AL, ap-
examined after 1 pears to be due to
year its relation to base-
line AL. Age was not
significant in model
with other baseline
clinical variables.
Grbic et al.103 Health and per- 75 patients with 41% with AL in >1 Authors note should
1991 sonal history ques- chronic Periodonti- sites; 21% with AL only generalize to a
USA tions; 3rd molar not tis. Minimum age in >2 sites. Logistic group seeking care
examined; PD, 30; minimum num- model for both of with disease and at
CAL, BOP, reces- ber teeth 18; >2
=
above outcomes least 18 teeth
sion. AL defined as sites of 5 mm AL in contained MAL at
change in attach- each quadrant; no baseline; age, and n
ment level over 6 relevant systemic missing teeth. For
months of >2.5mm. medical problems or >1 sites, odds of AL
Root planing and medications; no his- increase 6.8 times if
scaling after base- tory of antibiotic use MAL increased by
line exam last 4 months 2mm. If age in-
creased by 10
years, AL odds are
2.1 times higher.

Wennstrom et al.100 144 Measures made 511 subjects se- CAL was most pro- 225 of 298 eligible
1993 on all buccal, lin- lected from commu- nounced in the 18- (75.6%) were ex-
Sweden gual, and approxi- nity clinics. 3 age 29 age group. Mean amined. Regular at-
(1990) mal surfaces for cohorts (born 1949- loss of CAL and tendee had little
28 teeth. Gingivitis 60, 1932-48, before bone height was at tooth loss and peri-
= 2 or 3 score on 1931). All had > 12 similar magnitude in odontal disease.
Le and Silness, teeth and willing to young and old sub- Disease incidence
PD and CAL re- be in 5-year preven- jects did not increase with
corded to nearest tive dental program. age
mm In 1989, random
sub-sample to gen-
erate 4 age cohorts
of 70 each
AL attachment loss.
=
Gl =
gingival index.
CAL clinical attachment level.
=
MAL =
mean attachment loss.
CEJ cemento-enamel junction.
=
PD =
probing depth.

Annals of Periodontology
 Review: Periodontal Implications: Older Adults 341

Table 2. Continued
Author
Date of Publication
Country Length of Study
(Date of study if known) (in months) Methodology Sample Findings Comments
Brown et al.101 18 CAL calculated Random sample of Incidence of attach-
1994 from recession and 818 community peo- ment loss of >3 mm
USA PD measures on all ple in 5 N.C. coun- in 3 or more sites
(1990) teeth at buccal and ties age >65 strati- was 24% for blacks
mesiobuccal sites fied by race and ur- and 16% for whites.
rounded down to ban-rural status. Age For the 4 age groups,
next whole mm. groups were 65-69, there were no signifi-
Exam in homes by 70-74, 75-79, >80. cant differences in
5 calibrated exam- 611 subjects reex- the % of sites with at-
iners examining amined for 25% attri- tachment loss. Age
same people both tion rate was not a factor in
times the etiologic models
presented
AL attachment loss.
=
Gl =
gingival index.
CAL clinical attachment level.
=
MAL =
mean attachment loss.
CEJ cemento-enamel junction.
=
PD =
probing depth.

disease are found to be related to aging, it
appears that association is due to other fac-
tors.
PREVALENCE IN
INSTITUTIONALIZED INDIVIDUALS
(TABLE 3)
There is a long-standing interest in
whether older people who are institutional-
ized have worse periodontal status than
community-dwellers. For periodontists, this
translates into whether or not the fact that
a patient is institutionalized should impact
on a treatment plan.
From the 1960s to the early 1980s, when
dentist geriatricians were attempting to mo-
tivate their general dentist colleagues to pro-
confirm extensive treatment needs. Secular
trends for edentulism have demonstrated
that newer cohorts of people are reaching old
age with more teeth than previous cohorts
and as those older adults are institutional-
ized, there are ever increasing needs for
treatment of caries and periodontal disease.
Included in this review are only more recent
studies of the prevalence of periodontal dis-
ease in institutionalized older adults that
provide examples of the type of information
available.
Stuck and colleagues104 conducted a
study of admissions to one geriatric hospital
in Berne, Switzerland over a 6-month period.
This design provides some evidence of the
type of oral conditions extant on admission,
as all examinations were conducted within

vide care to nursing home residents, a
multitude of studies were conducted in
nursing homes to demonstrate the disease
levels and types of treatment needed by res-
idents. The vast majority of these studies
two weeks of admission. Over 59% of the 219
patients were edentulous. A high percentage
had tooth loss requiring free-end partials. Of
the remaining teeth, 29% were decayed and
45% had Periodontitis (PI score 6 or 8). =

documented the fact that most residents Overall, 98% of dentate patients needed
were edentulous and those that had teeth some dental treatment as did 31.5% of eden-

had much worse caries and periodontal con-
ditions. There is little sense in detailing
these earlier studies as most were simple
tallies of oral conditions or treatment needs,
most had significant methodological prob-
lems, and the evidence did little more than
tulous patients. The ability to generalize
these findings to other geriatric hospitals in
Switzerland or other countries is unknown.
The most extensive study involved 31
long-term care facilities in the U.S. and in-
dicated that 72% of the residents who were

Vol. 1, No. 1, November 1996

342 Beck

Table 3. Prevalence of periodontal disease measures related to age: institutionalized population (cross-sectional studies
by publication date)
Author
Date of Publication
Country Methodology Sample Findings Comments
Stuck et al.104 Interview with patient or All patientsover 65 ad- 59.4% edentulous. A high Indicates poor presenting
1989 proxy, mobility and men- mitted to geriatric hos- % had tooth loss requiring conditions to the institution.
Switzerland tal function assessed. pital for 6 months. 69 free-end partials. Of re- Ability to generalize find-
Oral exam by same per- men and 150 women maining teeth, 29% were ings is unknown
son within 2 weeks of with average age of decayed and 45% had Per-
admission. Number of 81.6 years iodontitis (PI =
6 or 8).
teeth, prosthetic needs, 98% of dentate needed
caries, and Periodontitis some treatment as did
using Russell's PI 31.5% of edentulous

Strayer & lbrahim7: Retrospective chart au- 318 nursing home pa- 80% female. Mostly eden- Not necessarily represen-
1991 dit over a 2-year period tient records and 123 tulous. 76% of nursing tative of nursing home and
USA of patients seen in nurs- homebound patient rec- home patients and 60% of homebound patients
ing homes and home- ords homebound had periodon-
bound. Recorded pro- tal/preventive procedures
cedures: preventive/per-
iodontal =
scaling, pro-
phylaxis, oral hygiene
instruction, periodontal
procedures
Ong et al.105 WHO 621 probe
to 68 nursing homes in 11.3% had PD of >6 mm. Analyses did not take into
1992 measure PD 6 sites Singapore. 4 homes
on 1.4% had no BOP. Mean of account the 2-stage sam-
Singapore per tooth, BOP, and randomly selected and 7.8 teeth. 51% were eden- pling process. Not clear if
calculus. One examiner 50% in each home ran- tulous. Those between 55 worst site per tooth was re-
domly selected result- and 65 most likely to have corded or ail sites per tooth
ing in 670 worse periodontal status

Kiyak et al.71 17 dentists and 22 4th 31 facilities responded 72% with poor oral hy- Not representative of full
1993 year dental students to free oral exam for giene, 43% with sore or range of residents. Multiple
USA were examiners. Train- their residents. A total bleeding gums, 18% with inexperienced examiners
ing was for 4 hours. of 1,063 residents cog- significant tooth mobility, with no evidence of calibra-
Exam was for presence nitively able to respond and 6% with intraoral swell- tion
or absence of intraoral to interview were ex- ing or suppuration. Sore
swelling or suppuration, amined and bleeding gums more
sore or bleeding gums, likely in larger, proprietary
tooth mobility, poor oral homes in rural or moderate
hygiene size communities
BOP =
bleeding probing.
on
PI =
periodontal index.
PD =
probing depth.

cognitively able to respond had poor oral hy-
giene, 43% had sore or bleeding gums, 18%
had significant tooth mobility, and 6% had
intraoral swelling or suppuration.71 In addi-
tion, sore or bleeding gums were more likely
in larger proprietary homes in rural or mod-
erate sized communities. These findings are
each home were selected.105 In this study,
which used the earlier version of the CPITN
to measure treatment needs, 11.3% of the
residents had probing depths of > 6 mm and
only 1.4% had no bleeding on probing. The
residents had a mean of 7.8 teeth while 51%
were edentulous. Since it appears that the

likely to be conservative as cognitively im- edentulous people were included in the

paired individuals usually have poorer oral mean number of teeth, residents with teeth
health. In Singapore, 4 homes were ran- likely had more than 7.8 teeth. Residents be-
domly selected to represent 68 nursing tween 55 and 65 were more likely to have
homes in the area and half the people in worse periodontal status. The final study

Annals of Periodontology
 Review: Periodontal
was unique in that it also reported on the
oral conditions of homebound residents, for
whom little is known.72 This was a record re-
view of treatment rendered these groups by
a mobile program associated with a dental
school. While not necessarily representative
of either group, records indicated that 80%
receiving treatment were female and that
76% of nursing home patients and 60% of
homebound patients treated had periodon-
tal/preventive procedures.
As with earlier studies, these studies con-
firm that nursing home residents have exten-
sive periodontal treatment needs. However
these studies provide almost no help in de-
termining the impact of institutionalization
on dental disease. One study indicates that
people aged 55 to 65 had worse periodontal
conditions. Since we do not know how long
they had been in the nursing facility, we do
not know if those conditions existed when
they were admitted, which is quite likely since
they are relatively young for nursing home
patients and must have significant medical
problems. In fact, they could be short-stay
residents admitted after surgical procedu-
res. The findings that periodontal conditions
are worse in large proprietary homes in
small to mid-size communities could be due
to lack of oral care in proprietary homes ver-
sus non-profit homes or could be due to peo-
ple from small communities having worse
periodontal status in general.
What do these findings tell us about per-
iodontal status in nursing homes? Almost
nothing beyond the fact that it is poorer than
in community-dwellers. Does institutionali-
zation affect periodontal status? We really do
not know as there are no longitudinal stud-
ies of this group. Should periodontists allow
the fact of institutionalization to affect their
treatment plans? Yes, because of the infor-
mation presented above. Nursing home pa-
tients are institutionalized for a reason. If
they are long-term residents, they usually
have severe medical and mental conditions
that involve loss of function. They may have
medical conditions or be taking medications
that impact on treatment that can be pro-
vided. They are unlikely to perform self care
as well as others, there are care-givers in-
volved in maintenance of oral health, and
Implications: Older Adults 343
there can be significant issues with informed
consent.
AGING AND PERIODONTAL RISK
FACTORS
Risk Factors From Incidence and
Clinical Studies (Table 4)
Prior to reviewing the evidence available,
several points of clarification are needed.
First, risk factors are appropriately deter-
mined by means of longitudinal studies.
Thus, factors identified in the prevalence
studies discussed above are not reviewed
here. Second, although many studies have
identified potential risk factors, those stud-
ies did not evaluate the potential risk factors
in light of other characteristics that may
confound the relationship. For example a
number of studies presented in Table 2
showed that age was related to the incidence
of attachment loss. However, when that re-
lationship was evaluated by means of a mul-
tivariate model, it was found in most studies
that other characteristics explained that re-
lationship and age was no longer significant.
Thus, only risk factors that hold up to scru-
tiny within a multivariate model are pre-
sented here. Third, we should pay attention
to the characteristics that are in the models.
Some characteristics are excellent predictors
of future disease, because they are alterna-
tive measures of that disease. For example,
baseline attachment level is a good predictor
of future disease, but it is not useful as a
risk factor, because it does not provide the
clinician with clues on how to intervene.
While it is useful to use baseline disease to
predict future disease, models that contain
these "predictors" may not provide as much
information as to potential risk factors for
the disease, because the "predictors" may
mask the presence of risk factors. For ex-
ample, models that contain characteristics
such as baseline disease level or number of
teeth often do not identify factors, such as
periodontal pathogens, as important. This is
because if periodontal pathogens are a true
risk factor for disease, then they are related
to disease level at baseline, which is a
Vol. 1, No. 1, November 1996
344 Beck

Table 4. Risk factors for periodontal disease measures according to age (cohort studies by publication date)
Author
Date of Publication
Country Length of Study Results
(Date of study if known) (in months) Methodology Sample (Risk Model) Comments
Papapanou et al.! 120 At least 6 periapical 283 of 531 dentate Multiple regression Same examiner for
1989 and 4 bite-wing films people with radio- model with bone level all. Site analyses did
Sweden obtained by stand- graphic exams in change per tooth site not account for non-
(1985-1986) ardized parallel tech-1974-76 randomly over 10 years. Fac- independent meas-
nique. Alveolar bone selected for new tors for more bone
level =
distance be- exam. 201 res- loss were less mean
tween CEJ and most ponded and films bone level 1974-76,
coronal along root were obtained from worse site bone level,
surface with perio- dentists of 54 non- distal site, maxilla,
dontal ligament space respondents canines and 1st pre-
normal width molars at lower risk.
Model r-square =

0.12
Ismail et al.102 336 One examiner in Baseline exam in Logistic model for No statistically or
1990 1959 and 3 in 1987 1959 of all commu- AL of > 2 mm over clinically significant
USA who were calibrated. nity-dwellers in Te- 28 years. Being differences in those
(1987) Gingivitis, calculus, cumseh Ml. 690 older and smoking in 80km radius and
mobility, PD, and AL (86%) received den- at baseline posi- those not. AL very
using Ramfjord meth- tal exam. 1987 exam tively related to AL. low over 28 years in
ods. AL at 4 sites per excluded people born Mobility at follow-up most people. Model
tooth before 1900 and out exam positively as- used mix of baseline
of 80km radius of sociated with AL and follow-up meas-
town. 167 examined ures
in 1987

Haffajee et al.' 12 CAL, PD, recession Random sample of Logistic model of > 1 Examiners followed
1991 measured at 6 sites/ 319 20-79 year-old sites of new AL of > same subjects. These
Japan tooth on all teeth residents of Ushiku, 3 mm. Age forced findings may have
Japan in longitudinal into model, but NS implications for other
study examined at in final model. % age-related periodon-
follow-up with no sites with PD > tal disease findings
treatment. 271 were 3mm, n of missing
examined after 1 teeth, and % sites
year with recession >
1 mm were signifi-
cant. Sn =
37.8%,
Sp 92.9%
=

Grbic et al.103 Health and personal 75 patients with 41% with AL in >1 Authors note should
1991 history questions; chronic Periodontitis. sites; 21% with AL in only generalize
to a
USA 3rd molar not ex- Minimal age =
30; > 2 sites. Logistic group seeking care
amined; PD, CAL, minimum number model for both of with disease and at
BOP, recession. AL teeth 18; > 2 sites
=
above outcomes con- least 18 teeth
defined as change of > 5 mm AL in each tained MAL, age, and
in attachment level quadrant; no relevant number missing teeth.
over 6 months of > systemic medical For > 1 sites, odds of
2.5mm. Root plan- problems or medica- AL increase 6.8
ing and scaling after tions; no history of times if MAL increa-
baseline exam antibiotic use last 4 sed by 2mm. If age
months increased by 10
years, AL odds are
2.1 times higher
AL attachment loss.
=
CEJ : =
cemento-enamel junction. Sn =
sensitivity.
BOP bleeding on probing.
=
MAL =
mean attachment loss. Sp =
specificity,
CAL clinical attachment level. PD
= =
probing depth.

Annals of Periodontology
 Review: Periodontal Implications: Older Adults 345

Table 4. Continued
Author
Date of Publication
Country Length of Study Results
(Date of study if known) (in months) Methodology Sample (Risk Model) Comments
Brown et al.101 18 CAL calculated from Random sample of Logistic model out- Etiologic models do
1994 recession and PD 818 community peo- come was > 2 sites not contain any fac-
USA measures on all ple in 5 N.C. coun- of AL of > 3 mm tors that are alter-
(1990) teeth at buccal and ties age > 65 over 18 months. Eti- native measures of
mesio-buccal sites stratified by race ologic model for the outcome; e.g., n
rounded down to and urban-rural blacks was Pi > of teeth
next whole mm. status. Age groups 2%, Pg > 2%, do
Exam in homes by 5 were 65-69, 70-74, not floss regularly,
calibrated examin- 75-79, >80. 611 memory worse, visit
ersexamining same subjects re-exam- > 3 years ago. Sn =

people both times ined for 25% attri- 77%, Sp 38%. =

tion rate Whites model was

Pg > 2%, medical
care in last 6
months, depressed,
smoke regularly. Sn
=
58%, Sp =
76%
Beck & Koch106 18 CAL calculated from Random sample of Logistic model for AL in the form of re-
1994 recession and PD 818 community peo- AL in form of in- cession has differ-
USA measures on all ple in 5 N.C. coun- creased probing ent factors involved.
(1990) teeth at buccal and ties age > 65 depth in buccal If older adults have
mesio-buccal sites stratified by race sites. Pi +, not tak- more recession, risk
rounded down to and urban-rural ing calcium, no cer- factors for younger
next whole mm. status. Age groups vical abrasion, and older people
Exam in homes by 5 were 65-69, 70-74, salivary flow 1+ml/ may differ
calibrated examin- 75-79, >80. 611 minute, gums bled
ersexamining same subjects reexam- last 2 weeks, and to-
people both times ined for 25% attri- bacco use. The op-
tion rate posite
characteristics were
related to AL mostly
in form of recession
Beck et al.107 36 CAL calculated from Random sample of Bivariate logistic Model contains pu-
1995 recession and PD 818 community peo- model for AL sepa- tative pathogens,
USA measures on all ple in 5 N.C. coun- rated into new le- medications, and
(1992) teeth at buccal and ties age > 65 sions and progres- behavioral factors.
mesio-buccal sites stratified by race sion of existing le- These factors differ
rounded down to and urban-rural sions. Factors were for new lesions ver-
next whole mm. status. 338 subjects income <$15,000, sus progressing le-
Exam in homes by 5 examined for 45% taking medications sions
calibrated examin- attrition rate with soft tissue reac-
ersexamining same tions, use smokeless
people both times tobacco, smoke cig-
arettes, BANA + Pg
+, perception of
worsening financial
situation
AL attachment loss.
=
CEJ : =
cemento-enamel junction. Sn =
sensitivity.
BOP bleeding on probing.
=
MAL =
mean attachment loss. Sp =
specificity,
CAL clinical attachment level. PD
= =
probing depth.

Vol. 1, No. 1, November 1996

346
stronger predictor. Thus, disease level at
baseline masks the effects of periodontal
pathogens. Consequently, models that con-
tain predictors are good for identifying peo-
ple at risk, but not as useful for identifying
risk factors.
Three studies use predictors in their mod-
els.9798103 Predictors identified were baseline
mean bone level, worst site mean bone level,
percent of sites with probing pocket depth >
3 mm at baseline, percent of sites with gin-
gival recession > 1 mm at baseline, mean
attachment loss at baseline, and number of
missing teeth at baseline. In these studies,
there were few additional factors identified.
One study103 found age to be related, one
study had no additional factors97 and one
study98 identified primarily tooth and site-
level variables; e.g., distal site, maxilla, ca-
nines, and first molars were at lower risk.
Smoking was identified as a risk factor by
all the remaining studies that included that
behavior.101 102 106 107 However, the Brown et
al.101 and the two studies by Beck106 107 were
based on different analyses of the same
study population. In fact, one of those stud-
ies106 found that tobacco use was associated
with attachment loss that occurred mostly
as deeper probing depth, while the other
study107 found that tobacco use was identi-
fied with new lesions and cigarette smoking
was identified with progression of existing
lesions.
Smoking was the only risk factor consis-
tently identified in the studies reviewed.
Other behavioral risk factors found in the
Brown et al. study of older adults101 were not
flossing regularly, dental visits greater than
3 years ago, and depression. Instead of iden-
tifying risk factors for attachment loss, the
Beck and Koch study106 used the same data
base as the Brown et al. study but focused
on identification of factors that differentiated
between attachment loss that occurred pri-
marily as increased probing depth as com-
pared to attachment loss that occurred
primarily in the form of increased recession.
Older adults who had Provotella intermedius
present, did not take calcium, had no cer-
vical abrasion, had a salivary flow of 1ml/
minute or greater, had gums bleed in last 2
weeks, and who used tobacco were more
Annals of Periodontology
Beck
likely to have attachment loss in the form of
increased probing depth. The opposite char-
acteristics were associated with attachment
loss primarily in the form of increased reces-
sion, indicating that attachment loss may be
more than one condition. Beck et al.107 also
looked at factors related to occurrence of at-
tachment loss in the form of new lesions ver-
sus progression of existing lesions over a
3-year period in older adults. Low income
and taking medications with a potential for
soft-tissue reactions were common to both
types of attachment loss. The only other fac-
tor associated with new lesions was tobacco
use. People who were BANA positive (indi-
cating that spirochetes were present in sam-
pled plaque), who were infected with P.
gingivalis, smoked cigarettes, and perceived
a worsening financial situation were more at
risk for disease progression.
A multitude of studies have implicated
microorganisms as periodontal pathogens.
However, most of those studies were focused
on microorganisms and did not evaluate
them in the presence of other risk factors in
longitudinal studies. Thus, there currently
are very few studies that qualify for this re-
view. The only study that employed meas-
ures of microorganisms in this group is
responsible for three of the articles.101106107
In all of these reports, microorganisms are
implicated as risk factors both for future at-
tachment loss and for the type of attachment
loss (also see Section 11).
Do Factors Differ for Different
Age
Groups?
The paucity of longitudinal studies that
attempted to identify risk factors for perio-
dontal diseases have not produced any di-
rect evidence to determine if risk factors
differ for younger versus older individuals.
However, indirect evidence does exist. Some
studies show that while age is associated
with periodontal disease, that association
does not remain significant when other fac-
tors are taken into account. This indicates
that other factors appear to differ for older
and younger adults. The question is, how-
ever, what are those other factors? Unfor-
tunately we mostly can only speculate on the
 Review: Periodontal
answers. The studies that contained sub-
jects representing a wide age range included
predictors in their models. Thus, all we
know is that the relationship between age
and attachment loss is affected by baseline
disease status. In addition, the studies that
did not include baseline predictors in the
models were primarily studies of older
adults and direct comparison of risk factors
with younger adults was not possible. How-
ever, the primary risk factors identified in
older adults involved general health status,
perhaps diminished immune status, taking
medications, depression, worsening mem-
ory, diminished salivary flow, functional im-
pairments, and change in financial status.
While these factors are not restricted to older
adults, they are more likely to occur among
the older chronological age group. Thus, it
may be that risk factors do change as people
age, or at least the relative importance of
risk factors change. However, it may also be
that there is a finite set of risk factors for
periodontal diseases and that some of those
risk factors are active across the age spec-
trum (e.g., microorganisms) while other fac-
tors come into play as a consequence of the
host's biological age.
AGING AND PERIODONTAL
OUTCOMES
Plaque and Gingival Inflammation
(Table 5)
Several studies have directly addressed
the issue of whether plaque build-up, onset
of gingivitis, and the healing of inflamed gin-
giva are affected by age. Holm-Pederson et
al.108 studied a young group of 10 dental stu-
dents and an older group of 11 adults aged
65 to 78 free of active disease, who refrained
from oral hygiene for 21 days prior to a pro-
phylaxis and oral hygiene. They found no
differences for mean GI and plaque scores,
although the older group had somewhat
higher scores. After the prophylaxis and re-
sumption of oral hygiene, GI scores declined
for both groups. There were no differences
found between the older and younger groups
on healing or percentages of bacteria, al-
Implications: Older Adults 347
though the older group had more gingival
exudate.
Different results were found in another
study109 of two groups, one aged 25 to 39 (N
=
7) and another aged 45 to 54 (N 6). Both
=
groups had 50% bone loss, but a currently
healthy periodontium. These groups ab-
stained from oral hygiene in one quadrant
for 18 days and then had a prophylaxis and
resumed oral hygiene. Plaque accumulated
rapidly in both groups and all subjects de-
veloped gingival inflammation. There were
no differences in swelling and redness in
both groups, but the younger group had ear-
lier onset and higher bleeding on probing
(BOP) scores. In the younger group, BOP
was related to increasing loss of attachment.
There were no differences found between
groups on redness, swelling and BOP after
the prophylaxis and oral hygiene. A study on
the same subjects110 reported that these pa-
tients with previous disease developed
plaque with high proportions of spirochetes
and supragingival plaque had high propor-
tions of motile organisms. They concluded
that the earlier BOP in the younger groups
was not explained by the host and organism
findings. It appears that both studies indi-
cate that the age groups do not differ in re-
covery from gingival inflammation, although
one study reports that the older group had
more gingival exudate and the other reports
that the younger group had earlier and
higher BoP scores. The problem with both
studies is that the findings of no differences
between the groups could simply be due to
small sample sizes. Thus, the trends found
that older adults had more gingival inflam-
mation and higher plaque scores could be
real.108 Consequently, there is controversy
and inconclusive results surrounding the
issue of plaque development, gingival in-
flammation, and inflammation reduction be-
tween older and younger adults.
Preventive and Surgical Outcomes
(Table 5)
While there is a great deal of literature in-
vestigating periodontal outcomes as a result
of preventive measures and surgical out-
comes, few studies have compared those
Vol. 1, No. 1, November 1996
348 Beck

Table 5. Aging and periodontal outcomes (by publication date)

Author
Date of Publication Study Type/ Parameters Subjects/
Country Methods Studied Controls Age Effects Comments
Holm-Peterson et al.108 Experimental/gingi- Experimental gingi- 10 dental students Mean Gl scores in- These were healthy
1975 vitis (Loe & Silness), vitis created by no (ages 20-24) and 11 creased in both older adults. A gen-
Sweden Pll gingival exudate oral hygiene for 21 healthy older adults groups (>1) and in- eral population may
assessed on lower days, then period of aged 65-78. Both creased over time. exhibit greater dif-
incisor, cuspid, and oral hygiene groups free of active Older group had ferences, but prob-
bicuspid areas. Bac- periodontal disease somewhat higher ably not due to age.
terial counts taken scores. After prophy- Small n indicates
laxis and oral hy- only exudate differ-
giene, both groups ence may be signif-
declined. Greatest icant
differences for gingi-
val exudate scores
with older group
much higher. No dif-
ferences in percent-
ages of bacteria.
There were no differ-
ences in rate of heal-
ing
van der Velden et al.109 Experimental/PII Experimental gingi- patients aged 25- Plaque accumula- Appropriate use of
7
1985 (Silness & Le), vitis. Baseline hy- 39, 6 patients aged ted rapidly in both proportional hazards
Netherlands color of gingiva (red, giene, no hygiene in 45-54. All had 50% groups and all sub- analysis. No differ-
not red), gingival 1 quadrant of mouth bone loss, a re- jects developed gin- ences could be due
swelling (none, light, for 18 days, then duced but healthy gival inflammation. to lack of power
obvious), BOP, PD prophylaxis and oral periodontium with No differences in swell-
with pressure probe hygiene probing depth < ing and redness in
3mm; therapy had the groups. Younger
been completed 2 group had earlier on-
years before start of set and higher BOP
study scores. In younger
group, BOP was re-
lated to increasing
loss of attachment.
After prophylaxis and
hygiene, no differ-
ences found between
groups on redness,
swelling, and BOP
Abbas et al.110 Experimental / same
Experimental gingi- 7 patients aged 25- After oral hygiene ab-
1984 as above, plus bac- hy- 39, 6 patients aged
vitis. Baseline stention, these pa-
Netherlands giene, no hygiene in 45-54. All had 50%
terial sampling for tients with previous
1 quadrant of mouth bone loss, a re-
spirochetes, motile disease developed
for 18 days, then duced but healthy
rods and histological plaque with high pro-
and immunohisto- prophylaxis and oral periodontium with portions of spiro-
chemical analyses hygiene PD < 3mm, and chetes. Supragingival
from biopsies therapy had been plaque had high pro-
completed 2 years portions of motile or-
before start of study ganisms. The earlier
BOP in the younger
groups is not ex-
plained by host and
organism parameters
studied
.

BOP =
bleeding on probing.
CAL =
clinical attachment level.
Gl =
gingival index.
Pll =
plaque index.
PD =
probing depth.

Annals of Periodontology
 Review: Periodontal Implications: Older Adults 349

Table 5. Continued
Author
Date of Publication Study Type/ Parameters Subjects/
Country Methods Studied Controls Age Effects Comments
Lindhe & Nyman1 Clinical study/PII, Pretreatment phase, 75 patients referred Compared intake Prime emphasis on
1975 Gl, PD, mobility, fur- surgical phase, re- for treatment. Ages exam for youngest treatment effects for
Sweden cation involvement call maintenance 26-79. At intake had (26-29, n 6) to old- entire group
=

phase lost average of 50% est (>60, n =

19)
of support, willing to groups. Pll, Gl, PD,
accept treatment, ca- and bone scores
pable of obtaining op- were very similar. No
timal plaque control, patients showed fur-
willing to return for ther loss of periodon-
recalls tal support after 5
years
Lindhe et al.112 Retrospective clini- PD, CAL 2 groups of patients In group A (moder- Group sizes may
1985 cal treated for Periodon- ately advanced dis- have been too small
Sweden titis using Widman ease with 20+ years to detect differences
flap and follow-up difference in age
care groups). Group B
(advanced disease
with 30+ years differ-
ence in age groups).
No difference in PD
and CAL by age after
surgery
Axelsson et al.113 Clinical; baseline in % surfaces with 375 assigned to pre- 84% available for 15- Site analysis not
1991 1971-72. Follow-up plaque, BOP, PD, vention group and year follow-up. There corrected for non-in-
Sweden for 15 years CAL, CPITN 180 to control. Age was a low incidence dependent meas-
groups, 20-35,36-50, of caries and almost ures
51-70. Prevention no further loss of per-
group received tooth iodontal tissue sup-
cleaning instruction, port. PD for 20-35
prophylaxis, topical group was 2.0mm,
fluoride every 2 for 36-50 group was
months for first 2 2.1mm and for 51-70
years, then every 3 group was 2.2mm.
months, then once Tooth loss was simi-
per year for last 9 lar for all groups. CAL
years showed an overall
gain with no differ-
ences among age
groups. Losing sites
were more common
in the 36-50 year old
group.
BOP bleeding on probing.
=

CAL clinical attachment level.

=

Gl =
gingival index.
Pll plaque index.
=

PD probing depth.
=

Vol. 1, No. 1, November 1996

350
outcomes by age group of the subjects. Lin-
dhe and Nyman111 studied 75 patients re-
ferred for treatment. At intake, subjects had
lost an average of 50% of support. These
subjects were willing to accept
and were judged capable of obtaining opti-
mal plaque control. Subjects were treated
with surgery and then maintenance. The
youngest group (aged 26 to 29; N 6) and
the oldest (over age 60; N 19) had similar
= It is ironic that this situation exists, because
plaque index, gingival index, probing depths,
and bone scores. No patients showed further
loss of periodontal support after 5 years, in-
dicating that age of the individuals is not re-
lated to success of therapy. A retrospective
study was conducted 10 years later112 on 2
groups of patients (Group A, 62 patients
with moderately advanced disease in 3 age
groups: < 40, 40 to 49, and > 49 and Group
B, advanced disease in 2 age groups; 6 pa-
tients aged 26 to 29 and 15 > aged 60). The
two groups were treated for Periodontitis us-
ing Widman flap surgery and follow-up care.
There were no differences in probing depths
and clinical attachment levels by age after
follow-up, which for group B was 14 years.
Axelsson et al,113 in a larger study that fol-
lowed patients over 15 years, essentially
confirmed the findings of the first two stud-
ies that it is possible to prevent almost all
attachment loss and the results do not differ
substantially by age group.
Again, the sample sizes in two studies
were small, meaning that the findings of no
differences by age could be misleading. How-
ever, in the second study for Group A,112
there may have been as many as 20 people
in each group, which gives somewhat more
confidence in the findings of no difference.
In addition, the data indicate no real trends
for one group having a poorer response than
the other. Thus, the evidence to this point
indicates that age does not have an influ-
ence on healing of the periodontal tissues or
on the incidence of recurrent disease.
Systemicand Topical Medication
Outcomes
While there is evidence documenting
progression of periodontal diseases
younger and older adults as well as
Annals of Periodontology
Beck
pertaining to risk indicators and risk factors
for these diseases, there is little evidence on
outcomes of various therapeutic interven-
tions for older as compared to younger per-
treatment iodontal patients. In most instances, the
clinician's choice of therapy for an older pa-
tient must be made without specific knowl-
edge that patients at either end of the age
=
spectrum will respond in a similar manner.
most randomized, clinical trials have in-
cluded both older and younger periodontal
patients. However, most trials were sized to
test the effects of interventions on all sub-
jects and there were not enough participants
in each age group to report the results sep-
arately. Thus, most journals would be in-
clined to exclude data for which there was
inadequate power to reject the null hypoth-
esis. If studies had reported results by age
group, meta-analytic techniques might have
generated additional information on age dif-
ferences by combining results from a num-
ber of studies.
More than 100 studies of non-surgical
treatment regimens were reviewed in order
to determine if it were possible to find stud-
ies of a specific treatment with enough sim-
ilarities that data on specific age groups
could be requested from the authors to con-
duct a meta-analysis. Treatments reviewed
included systemic and local metronidazole
therapy and tetracycline therapy, alone or in
combination with other adjunctive thera-
pies, as well as topical Chlorhexidine ther-
apy. The results of this review were not
productive in that the vast majority of stud-
ies have few similarities.
Alternative Outcomes (Table 6)
The appropriateness of using the same ex-
pected outcomes for disease status across
people of different ages has been pondered
and debated for some time. The issues have
revolved around whether a given level of dis-
ease should be considered to have the same
consequences in younger and older people.
A companion issue involves whether to in-
the tervene, when to intervene, and if outcomes
in should be expected to be uniform for people
evidence
 Review: Periodontal Implications: Older Adults 351

Table 6. Alternative periodontal outcomes related to age

Author
Date of Publication
Country Study Type Methodology Sample Results Comments
Papapanou et al. Cross-sectional Standardized parallel Volvo employees Results were similar Study designed to test
1990 x-rays evaluated for n sampled into 4 age by age group. If BOP above model and
Sweden of teeth (28) and strata: 31-35, 41-45, were the criterion, compare to other clin-
ABL-PD to nearest 1 51-55, 61-65. 196 70% of sites needed ical parameters. Illus-
mm on worst site per subjects (82.7%) treatment. If PD > 4 trates differences in
tooth, AL to nearest 1 agreed to study. 4 mm is added, then treatment objectives,
mm, plaque by Pll, were edentulous and 27.5% need treat- remove all signs of
and BOP excluded ment, if BOP and PD disease vs. intervene
> 6 mm are criteria, to prevent tooth loss
then 4.1% need when older
treatment, and if
BOP and ABL > limit
are criteria, then
2.5% of sites need
treatment

Wennstrom et al. Cohort At least 6 periapical 194 patients whoA goal was estab- A model for bone level
1990 and 4 bite-wing films had radiographic ex-
lished to have 1/3 of by site and age is pre-
Sweden obtained by standard- ams about 10 years root length left at sented that presents
ized parallel tech- apart. Ages were age 75. Each site the bone levels at each
nique. ABL =
dis- between 25 and 70 within people by age age in which interven-
tance between CEJ and were grouped in group was evalu- tion is needed to
and most coronal 5-year age groups ated to see if bone achieve the goal at age
along root surface level and the rate of 75. Approach assumes
with periodontal liga- loss was consistent that all periodontal con-
ment space normal with reaching that ditions do not require
width goal. Only the distal intervention, only those
aspect of maxillary that will result in tooth
premolar and 2nd loss. Subjects appear
molar had levels to be similar to other
that would result in samples reported in
less than 1/3 root Sweden in rate of dis-
length support at 75 ease progression.
and would need in- Groups with different
tervention. Goals of rates would need mod-
1/2 and 2/3 root ified models
length resulted in
more needed inter-
vention
ABL alveolar bone loss.
=

AL attachment loss.
=

BOP bleeding on probing.

=

CEJ cemento-enamel junction.

=

PD probing depth.
=

Pll=
plaque index.

of different ages. However, few actual data-
based studies have been reported.
Papapanou et al.114 proposed an alterna-
tive model for deciding how much treatment
is needed. This model is based on the idea
that it is not always possible to treat and ar-
rest all clinical signs of inflammation in all
destructive periodontal disease (tooth loss).
Thus, they set the goal of therapy to allow
an individual to reach age 75 with at least
one-third of the root length remaining for
each of their teeth. They studied changes in
alveolar bone level over a 10-year period in
a group of 194 patients between age 25 and

people and that it may be useful to consider 70 to determine for each age group the level
the goal of periodontal treatment to prevent of bone support necessary to reach the goal,

Vol. 1, No. 1, November 1996

352
given the average rate of bone loss. The au-
thors present models for each tooth at the
mesial and distal sites by age to indicate
when intervention is necessary. In the data
presented, only the distal aspect of the max-
illary premolar and second molar had levels
of bone loss that would not allow the goal to
be met. This approach is based on disease
progression for this sample, which appears
to be similar to other studies reported in
Sweden. However, the models would need to
be based on the disease progression rates in
the target group.
A follow-up study115 by the same group
was designed to test the above model to il-
lustrate the differences between two treat-
ment objectives: remove all signs of disease
(CPITN measures) versus intervene to pre-
vent tooth loss when older. The results
showed that if BOP were the criterion, 70%
of sites needed treatment. If PD 5= 4 mm is
added as a criterion, then 27.5% needed
treatment. If BOP and PD 3= 6 mm are cri-
teria, then 4.1% needed treatment. Finally,
if bone loss greater than the model limits
was the criterion, then 2.5% of sites needed
treatment. Consequently, if retaining teeth
to old age is the treatment goal, then for this
group, it appears that little treatment is
needed and older adults need less interven-
tion than younger adults.
STATE OF KNOWLEDGE
This section summarizes the state of our
knowledge regarding periodontal diseases
and aging. While the typical call for more re-
search will not be made, it should be obvious
from this summary where more information
is needed.
1. Few, if any, randomized, controlled tri-
als exist that provide information about the
relationship of aging to periodontal diseases.
2. For studies reviewed, the most com-
mon methodological problem observed was
the absence of any indication that the sam-
ple sizes used had enough power to detect
differences. In some areas, the majority of
findings are suspect due to this problem.
Another common problem involved studies
that used site-based analyses that did not
account for non-independent measures, a
Annals of Periodontology
Beck
phenomenon that occurs when multiple
measures are taken in the same individual.
3. While randomized trials exist regarding
medicinal treatment modalities, none of
those trials reported differences by age.
Thus, the results of these trials only pro-
vided information as to the efficacy of the
treatment on the "average aged" individual.
4. Most cross-sectional studies that in-
cluded subjects across the age spectrum
have found that older individuals have worse
periodontal status. This generalized infor-
mation, however, is of little use to practition-
ers who must treat the periodontal condi-
tions unless it is clear whether it is becoming
older that is related to a worsening periodon-
tium or whether the worsening periodon-
tium is really related to other characteristics
that are related both to becoming older and
to periodontal disease. Studies that con-
trolled this relationship for other subject
characteristics usually found that age was
no longer important, although there were ex-
ceptions. There is no doubt that older groups
have worse periodontal status, but the evi-
dence on whether these are age-associated
or changes due to aging is mixed.
5. There are some incidence studies that
investigate whether periodontal disease is
more likely to occur or progress in older peo-
ple. The preponderance of current evidence
indicates that the relationship between age
and periodontal disease is age-associated,
rather than being a consequence of aging.
When higher incidence rates of periodontal
disease are found to be related to aging, it
appears that association is due to other fac-
tors.
6. Although numerous studies confirm
that dentate nursing home residents have
extensive periodontal treatment needs, these
studies provide no evidence on the impact of
institutionalization on dental disease. One
study indicates that people come to geriatric
facilities with poor oral health.
7. Longitudinal studies show that base-
line disease measures are the best predic-
tors of future risk, but these measures are
not useful for planning interventions.
8. Risk factors identified through longi-
tudinal studies that consider multiple fac-
tors in combination with each other indicate
 Review: Periodontal
that smoking is a risk factor for disease pro-
gression. Other risk factors identified in at
least one study were; not flossing regularly,
more than 3 years since last dental visit, de-
pression, low income, presence of P. gingi-
valis, presence of P. intermedius, and BANA
positive.
9. There only is indirect evidence indicat-
ing whether risk factors differ for different
age groups. This evidence comes from the
fact that the relationship between age and
periodontal status is modified by other char-
acteristics. There is little evidence on what
these other characteristics may be, but pos-
sibilities are general health status, dimin-
ished immune status, taking medications,
depression, worsening memory, diminished
salivary flow, functional impairments, and
change in financial status. It may be that
risk factors do change as people age, or at
least the relative importance of risk factors
change. However, it may also be that there
is a finite set of risk factors for periodontal
diseases and that some of those risk factors
are active across the age spectrum (e.g., mi-
croorganisms) while other factors come into
play as a consequence of the host's biologi-
cal age.
10. There have been a number of studies
investigating the relationship between age
and susceptibility to gingivitis, healing from
inflammation, surgery outcomes, and out-
comes of preventive regimens. Most of these
studies show trends, but no statistical dif-
ference in outcomes for younger and older
individuals. Lack of adequate sample sizes
in many of these studies could have resulted
the the finding of no difference. Thus, these
lack of relationships have not been defini-
tively established.
11. The feasibility of alternative outcomes
based on age have been discussed, but only
one group of researchers has conducted
data-based studies. If outcomes are based
on intervention only when tooth status is not
consistent with maintaining one-third of the
a tooth's root length at age 75 rather than
arresting all clinical signs of inflammation in
all people, then few people need interven-
tion. Furthermore older adults may need
less intervention than younger adults. The
ability to generalize these findings depends
Implications: Older Adults 353
on the rate of disease progression in the
group of interest.
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Demographics
Distribution of Older Adults in the Population
1. Ettinger RL. Demography and dental needs, an in-
ternational perspective. Gerodontology 1993; 10:3-
9.
2. Ainamo A, Osterberg T. Changing demographic
and oral disease patterns and treatment needs in
the Scandinavian populations of old people. Int
Dent J 1992;42:311-322.
3. U.S. Senate Subcommittee on Aging, American As-
sociation of Retired Persons, Federal Council on
Aging, et al. Aging America: Trends and Projections.
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