As the global population ages, the demand for holistic healthcare services, including oral health care, is rising significantly. According to the World Health Organization (WHO), the number of people aged 60 and above is projected to double from 1 billion in 2020 to over 2 billion by 2050, with the majority residing in low- and middle-income countries (1). The nations of the Association of Southeast Asian Nations (ASEAN) are collectively undergoing a rapid and significant demographic shift toward an aging population. While the pace of this transition varies across the region, most ASEAN countries are projected to become aging societies within the next few decades (2).Thailand and Singapore are at the forefront of the aging trend in ASEAN and are classified, as “aged societies” with Vietnam and Malaysia are currently considered “aging societies”. Counties like Cambodia and the Philippines still have relatively young populations, however, they are also aging rapidly. Despite this demographic shift, oral health care among older adults remains a neglected component of overall health, often overshadowed by the management of chronic systemic conditions.
Oral health issues among the elderly population are diverse and often complex. Common conditions include dental caries, particularly root caries due to gingival recession and reduced salivary flow; periodontal disease, which remains a leading cause of tooth loss; and edentulism, which continues to affect many older adults, especially in underserved regions (3). Xerostomia, often a side effect of medications used to manage chronic diseases such as hypertension and depression, further exacerbates the risk of caries and oral infections (4). Additionally, older adults are more susceptible to oral mucosal lesions, fungal infections, and oral cancers, particularly among tobacco and alcohol users. Unfortunately, these conditions often go undiagnosed or untreated due to limited access to dental care, low awareness among patients and carer, or prioritisation of other health issues.
Treating elderly patients poses unique challenges. Physical limitations such as frailty, cognitive decline, and mobility impairments may restrict their ability to attend dental clinics. Financial constraints also play a significant role, as many older adults live on fixed incomes, making dental care unaffordable (5). Psychological factors, including fear of dental procedures or social isolation, may further prevent them from seeking care. From the provider’s perspective, dental practitioners may feel inadequately trained to manage geriatric patients with complex medical conditions or may lack access to facilities equipped to accommodate these patients (6). Additionally, systemic barriers such as limited domiciliary dental services and inadequate integration of oral health into primary and geriatric care further hinder effective service delivery.
To address these challenges, modifications in dental care approaches for older people are essential. A comprehensive assessment that includes a detailed medical history, functional status, and medication review is crucial. Treatment plans should be simplified, focusing on disease prevention, pain control, and maintaining oral function and comfort rather than pursuing aggressive interventions (7). We are sharing the simplified ideas for treatment planning in managing older people; refer to Figure 1 to Figure 5. For institutionalised or homebound elderly patients, domiciliary dental services offer a practical and humane solution, enabling care delivery within residential facilities or private homes (8). Effective communication strategies, including involving caregivers or using audio-visual aids, can improve patient cooperation and understanding. Preventive measures such as fluoride varnish application, chlorhexidine rinses, and regular professional cleanings are critical in reducing disease burden.
Fig. 1: Considerations of age. Treatment planning for an elderly patient who is 60 years versus 94 years old may be different with multiple other factors and challenges.
Fig. 2: Considerations of medical problems and associated oral implications. There is a need to identify any risks of bleeding/infection/others (such as medication related-osteonecrosis of the jaw: MRONJ). The management may ends up be simpler interventions (for example; relining instead of fabricating a new denture) or even palliative care (for example; treat only symptomatic teeth that has acute abscess).
Fig. 3: Considerations of medications side-effects/polypharmacy and associated oral implications. There is a need to identify any risks of bleeding/infection/others (such as medication related-osteonecrosis of the jaw: MRONJ) For example; Direct oral anticoagulant (DOAC) is a common alternative to older medications like warfarin therefore there it carry a significant risk of bleeding especially in a higher bleeding risk procedures such as multiple teeth extractions and extensive periodontal surgery.
Fig. 4: Considerations of oral conditions and/or pathology. It is essential to consider the related issues/problems for a successful treatment. For example; xerostomia or dry mouth presents significant and unique challenges in the fabrication and long-term success of dentures. Saliva is a crucial component of oral function, especially for denture wearers and its absence or reduction may compromises the prosthetic process or ability to wear denture.
Fig. 5: Considerations of other issues. Dental treatment planning for elderly patients is a complex process that goes beyond standard care and with the need for holistic approach. For example: activities of daily living (ADL) may be impaired with decreased dexterity; make it difficult to perform basic oral hygiene tasks like brushing/flossing effectively. It may further be challenging with poor motivation for such tasks.
The implications of poor oral health in the elderly extend far beyond the mouth. Difficulty in chewing due to tooth loss or illfitting dentures may lead to poor nutritional intake, weight loss, and malnutrition (9). Oral pain, infections, and untreated lesions can significantly impair quality of life, affecting speech, sleep, and psychological well-being. Poor oral hygiene is also a known risk factor for aspiration pneumonia, particularly among frail, hospitalized, or institutionalized patients (10). Moreover, oral health is intricately linked to systemic health. Studies have shown strong associations between periodontal disease and cardiovascular disease, diabetes mellitus, and cognitive decline (11,12). Chronic inflammation originating from the oral cavity can contribute to systemic inflammation, further complicating existing medical conditions.
In conclusion, as we navigate the era of aging societies, addressing the oral health needs of older people must become a public health priority. Oral health care should be integrated into general health services for the elderly, with policies that promote accessibility, affordability, and age-friendly dental services. Dental practitioners must be equipped with the skills and resources to provide personcentered, dignified care to older adults. Through collaborative, preventive, and adaptive strategies, we can ensure that older individuals age with better oral function, improved quality of life, and holistic health.
Co - Author
Dr. Norjehan Yahaya is a Specialist in Special Care Dentistry at Kuala Lumpur Hospital. She graduated with a Doctor of Dental Surgery from Dalhousie University in 2002 and earned her Doctor of Clinical Dentistry from the University of Melbourne. A pioneer in Special Care Dentistry in Malaysia, she has contributed to developing policies and guidelines, including for the management of haemophilia. Her clinical focus is on dental care for medically complex cases, especially patients with bleeding disorders.
Dr. Norjehan Yahaya
Editorial note:
References
1. World Health Organization. Ageing and health. [Internet]. 2022. Available from: https://www.who.int/news-room/fact-sheets/detail/ageing-and-health
2. Tiraphat S, Kasemsup V, Buntup D, Munisamy M, Nguyen TH, Myint AH. Active aging in ASEAN countries: Influences from age-friendly enviroments, lifestyles and socio-demographic factors. Int J Environ Res Public Health. 2021: e.2022; 18(6)
3. Petersen PE, Yamamoto T. Improving the oral health of older people: the approach of the WHO Global Oral Health Programme. Community Dent Oral Epidemiol. 2005;33(2):81–92.
4. Thomson WM. Dry mouth and older people. Aust Dent J. 2015;60 Suppl 1:54–63.
5. Lee JY, Watt RG, Williams DM, Giannobile WV. A new definition for oral health: implications for clinical practice, policy, and research. J Dent Res. 2017;96(2):125–127.
6. Kossioni AE, Vanobbergen J, Newton JP, Müller F, Heath R. The development of undergraduate gerodontology curriculum in European dental schools. Eur J Dent Educ. 2009;13 Suppl 1:3–8.
7. Ettinger RL. Oral health and the aging population. J Am Dent Assoc. 2007;138 Suppl:5S–6S.
8. Marchini L, Ettinger R. Domiciliary dental care for the elderly: reaching out to a vulnerable population. Spec Care Dentist. 2012;32(3):105–110.
9. Sheiham A, Steele JG, Marcenes W, et al. The impact of oral health on quality of life in older people: a review. Gerodontology. 2001;18(2):95–103.
10. Azarpazhooh A, Leake JL. Systematic review of the association between respiratory diseases and oral health. J Periodontol. 2006;77(9):1465–82.
11. Preshaw PM, Alba AL, Herrera D, Jepsen S, Konstantinidis A, Makrilakis K, et al. Periodontitis and diabetes: a two-way relationship. Diabetologia. 2012;55(1):21–31.
12. Kamer AR, Craig RG, Dasanayake AP, Brys M, Glodzik-Sobanska L, de Leon MJ. Inflammation and Alzheimer’s disease: possible role of periodontal diseases. Alzheimers Dement. 2008;4(4):242–50.
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