Nursing Homes Neglect Teeth

On Tuesday, the Science section of the New York Times featured an article with the headline “Nursing Homes Neglect Teeth.”  The article stopped me in my tracks.  The situation is serious because nursing home residents suffer from tooth decay, gum disease, broken teeth and ill-fitting dentures.

I experienced the situation first hand with my mom, even though she was in a very highly regarded nursing home before she passed away.  She wore a removable partial denture but when a tooth broke, she needed a new partial denture.  The nursing home employed a part-time dentist (not common at most nursing homes) but the care was substandard. She went toothless for months while they presumably were constructing a new denture which never fit properly anyway. Finally I brought in my instruments and treated her myself.

Nursing home residents today require more dental care than in the past because more of the elderly are keeping their teeth.  The nursing staff is overworked and oral hygiene falls to the bottom of the to-do list.  Dentures are easier to keep clean. New studies show that lack of tooth hygiene may contribute to pneumonia among the elderly.  A 2008 review stated that one in 10 nursing home deaths from pneumonia may have been prevented by improved oral hygiene.

In Wisconsin nearly 1,100 nursing home residents were examined.  Over 30% had teeth that were broken to the gums and 35% had extensive plaque.  A 2006 study of nursing homes in New York State found that only 16% of residents had any oral care at all.  Tooth brushing of nursing home residents was federally mandated in the Budget Act of 1987 which established higher standards for nursing homes. Nevertheless, residents’ dental health is of low priority in the majority of nursing homes.

The problem is compounded because many of the elderly arrive at nursing homes with decayed and broken teeth.  Nursing homes are not equipped to provide the level of care needed.  On top of this, nearly 2/3 of long-term residents have dementia and may resist allowing the nursing staff to brush their teeth.  Additionally, prescription drugs such as antidepressants, high blood pressure medications and anti-seizure medications may contribute to reduced saliva, dry mouth and the resulting decay.

Question of the day in the New York Times Science section: “Are oral plaque, coronary vessel plaque and eye plaque the same substance?”  http://www.nytimes.com/2012/02/07/science/are-all-plaques-the-same.html?_r=1.  The answer is that coronary plaque and eye plaque are related but oral plaque is entirely different.

Coronary plaque that causes atherosclerosis is a soft and greasy substance of cholesterol and inflammatory cells that circulate in the bloodstream.  Eye plaque is a cholesterol filled bubble broken off from other atherosclerotic plaque.  But dental plaque is different: it is made up of bacteria, proteins, sugars and salts.  Buildup produces acid that leads to tooth decay and gum disease

Poor oral hygiene is linked to a higher risk of heart disease.  This is probably due to the inflammation produced by the plaque and with damage from the oral bacteria released into the blood.

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Several communities in the United States have stopped adding fluoride to their water systems.  Recently Pinellas County in Florida elected to stop adding fluoride to its public water supply although they just started the program 7 years ago.  Two hundred other communities have also stopped fluoridating in the past four years.  They are motivated by the economic downturn and by concern about the benefits of fluoride.

The US Public Health Service and the Centers for Disease Control and Prevention maintain that it is a mistake to end public water fluoridation.  The Federal government recommends water fluoridation, a practice which began in the 1940’s.  About 72% of the American population drinks fluoridated water.

Although fluoride has been demonstrated to decrease tooth decay, large amounts can lead to dental fluorosis, or brown spots on the teeth.  In 2011 The federal Department of Health and Human Services recommended reducing the amount of fluoride added to the water supply to 0.7 milligrams per liter of water.  The old standard ranged from 0.7 to 1.2 milligrams per liter.

Did you know that Suffolk County water is not fluoridated? Many times people do not realize this.

A lovely young lady came into the office last week with a complaint of brown spots on her teeth.  She needed to know that these brown spots were decayed spots (cavities).  The spots were not merely cosmetic but needed to be restored immediately before further damage occurred to her teeth.  The spots (really pitted areas in the enamel) were caused by plaque accumulation around her orthodontic brackets.  As a teenager her oral care was not as thorough as it could have been.  The acids from the bacteria resting on the plaque destroyed the enamel.  She did not visit the dentist the entire time of her orthodontic treatment.  Luckily I will be able to restore her teeth and she is determined to take better care of her teeth from now on.

He came into the office yesterday.  “I have bad teeth,” he said.  How may times have I heard that said?  But it’s not “bad teeth” – it’s bad dental care or lack of dental care.  If you don’t schedule regular visits to the dentist, what do you think happens?  Small cavities become larger cavities, teeth become abscessed, teeth break, teeth fall out.  If you don’t practice good oral hygiene, what do you think happens?  Bacteria sit on the teeth and gums, acids form, plaque and calculus adheres, pockets of infection form, the bone recedes, the teeth loosen and fall out.  We see this every day.  If you seek bargain dentistry, what do you think happens?  Fillings aren’t done carefully and the tooth develops marginal decay, crowns don’t fit properly and fall out, root canals become re-infected.  We see this every day.  So seek the best dental care and visit the dentist regularly before problems develop; don’t look for a bargain.  Your teeth are worth the investment and you won’t be saying, “I have bad teeth.”

Yes, we all know that sugar is bad for the teeth and leads to cavities.  But did you know that if you eat frequent small amounts of sugar you have a higher risk of decay than if you eat large amounts of sugar less frequently?  This means that the total quantity of sugar that you eat is less important than how the sugar is eaten.

Tooth decay occurs because bacteria normally in the mouth thrive on simple sugars and create acids that destroy tooth enamel.    It takes bacteria less than half a minute to convert sugar to acid.  This acid lasts for 30 minutes.  This means that if you sip soda slowly all day, acid is continually being produced.  A large soda consumed at one sitting will cause less tooth damage.

Parents are advised to moderate the use of toddler sippy cups because they encourage slow sipping – thus slow acid formation.  Sippy cups have been linked to tooth decay.

Sugar is not the only culprit.  Any acidic food or drink – such as diet soda- can cause tooth decay.  Sour candies cause more destruction than sweet candies.

Recent research on sugar and decay can be found on:  “It’s More Than Just Candy: Important Relationships Between Nutrition and Oral Health,” written by Carole A. Palmer, professor of public health at Tufts University School of Dental Medicine.  http://www.nursingcenter.com/library/journalarticleprint.asp?Article_ID=1047961

Of course, brushing and flossing after eating won’t hurt.  And regular visits to the dentist too!

Several years ago I read the book The Tipping Point by Malcolm Gladwell.  The tipping point is defined as the level at which the momentum for change becomes unstoppable.
It is a “moment of critical mass” or a threshold.  The book describes the many tipping points in our society in which a trend crosses a threshold, tips, and spreads through the public. Sometimes I use the tipping point concept to explain dental disease to my patients.  Their teeth may have large worn out fillings, heavy deposits of calculus, and be battered by uneven occlusion.  Then a tipping point is reached and the teeth break from the stress.

The challenge is to get people to restore their teeth before the tipping point is reached.