The epidemiology, consequences

and management of periodontal disease

in older adults
Tobias K. Boehm, DDS; Frank A. Scannapieco, DMD, PhD

s baby boomers near

retirement, dentists are
faced with increasing
numbers of older
patients who have
various types of periodontal disease
(PD). Since PD in older adults is
common and the consequences of
PD are significant, we summarized
the literature on this topic to help
general practitioners manage the
care of these patients.
In May 2007, we performed a
systematic PubMed search using
the terms periodontal disease OR
periodontitis and older adults.
Key words such as geriatric, dentistry, community-dwelling,
independent-living, nursing
home or dependent did not provide additional relevant articles at
the time we conducted our literature search. We evaluated 649 articles for relevance and validity and
selected key references for the following subtopics: epidemiology of
PD in older adults, oral and systemic sequelae, and management of
PD in older adults.
CASE REPORT

Case report. A 69-year-old woman

who had moderate generalized
chronic periodontitis came to the
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JADA, Vol. 138

ABSTRACT
Background. This review summarizes the literature on periodontal
disease (PD) in older adults. The authors focused on significant sequelae
of PD and therapy in this population.
Types of Studies Reviewed. The authors conducted a search on
PubMed for human studies using the terms periodontal disease OR periodontitis and older adults. They retrieved 649 articles and excluded
studies that had poor experimental design. For each topic of the review,
they selected one to three of the most recent studies or reviews for inclusion and cited classic articles where appropriate.
Results. PD is a common oral chronic inflammatory disease often found
in older adults. In older patients, PD may lead to root caries, impaired
eating and socialization. It also may increase patients risk of developing
systemic diseases such as diabetes mellitus, lung disease, heart disease
and stroke. Treatment is not limited by chronological age but depends on
the patients medical and emotional status and the availability of financial resources.
Clinical Implications. General dentists usually can treat the
majority of older people with mild or moderate PD. For older adults who
are medically compromised and dependent, the literature supports treatment that prevents PD progression.
Key Words. Periodontics; geriatrics; caries; vulnerable populations;
periodontitis.
JADA 2007;138(9 supplement):26S-33S.

Dr. Boehm is a research assistant, Department of Oral Biology, School of Dental Medicine, University at
Buffalo, The State University of New York, and a resident, Department of Periodontics and Endodontics,
School of Dental Medicine, University at Buffalo, The State University of New York.
Dr. Scannapieco is a professor and the chair, Department of Oral Biology, School of Dental Medicine,
University at Buffalo, The State University of New York, Foster Hall, Buffalo, N.Y. 14214, e-mail
fas1@buffalo.edu. Address reprint requests to Dr. Scannapieco.

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Figure 1. Initial presentation of a 69-year-old woman. A. Buccal right view showing gingival recession. B. Labial view showing gingival
recession, plaque deposits and gingival bleeding. C. Buccal left view showing notable gingival recession. D. Palatal right view showing
marginal erythema near tooth no. 4 and recession. E. Palatal view of anterior teeth. F. Palatal left view. G. Lingual right view of molars
with marginal erythema and bulbuous interdental papillae. H. Lingual view of anterior teeth showing calculus deposits and gingival
bleeding. I. Lingual left view showing marginal erythema on tooth no. 19.

postgraduate periodontics clinic at the School of

Dental Medicine, University at Buffalo, The State
University of New York in May 2007 (Figure 1).
She denied having any current symptoms of oral
disease; however, she reported that over the last
20 years, her anterior teeth have moved slightly
out of place. She was taking metoprolol,
hydrochlorothiazide and atorvastatin for treatment of hypertension and dyslipidemia, and her
dental history revealed periodontal surgical treatment 10 years ago and fair oral hygiene.
We conducted an oral examination and found
recurrent caries on teeth nos. 17 and 31, generalized 3- to 4-millimeter pocketing with isolated 5to 8-mm pockets in the mandibular molar areas
and generalized bleeding on probing. Her teeth
exhibited no greater mobility than Miller class I,
with no fremitus. When we evaluated her oral
hygiene, we found insufficient interproximal
plaque removal (OLeary plaque index score of 44
percent). Radiographic examination confirmed

caries and provided evidence for 3 to 4 mm of generalized bone loss and furcation involvement of
tooth no. 30. We saw no evidence for other bony
defects. We found localized plaque and calculus
deposits in the areas of marginal erythema, and
gingival recession and pathological tooth migration provided evidence of past PD activity (Figure
1). The treatment plan involved oral hygiene
instructions, scaling and root planing at selected
sites, caries removal, and restoration and flap
surgery if deemed necessary after initial therapy.
This case illustrates the importance of good
long-term follow-up, as the patients oral hygiene
measures had fallen behind and some sites exhibited active PD. Although general practitioners

ABBREVIATION KEY. COPD: Chronic obstructive

pulmonary disease. CVD: Cardiovascular disease.
PD: Periodontal disease. VAP: Ventilator-associated
pneumonia.

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TABLE

of these subjects had

attachment loss of 8 mm or
Prevalence rates of periodontal disease in subjects,
greater (advanced PD),
by study.
implying that PD in older
SUBJECTS (COUNTRY, AGE,
PREVALENCE RATES
STUDY
people is limited and can
LIVING SITUATION)
be treated successfully by
2.4% healthy
Krustrup and Erik
Denmark, 65 to 74 Years Old,
general dentists. Similar
93.1% bleeding on probing
Petersen
Community-dwelling
studies of German3 and
62.1% pockets 4-5
millimeters
Japanese4 populations
20.0% pockets > 5 mm
demonstrated a similar
Levy and colleagues
91% 4 + mm attachment loss
Iowa, Mean Age 85 Years,
prevalence of PD. The
45% 6 + mm attachment loss
Community-dwelling
German study demon15% 8 + mm attachment loss
strated lower prevalence of
Mack and
60-69 years: 79% 4 + mm
Germany, 60 to 80 Years Old,
PD in women and people of
colleagues
pocket depth, 37% 6 + mm
Community-dwelling
pocket depth
advanced age with
70-79 years: 68% 4 + mm
increased tooth loss.4 The
pocket depth, 30% 6 + mm
pocket depth
Japanese study found
Males > females
abutment teeth of partial
60-69 years > 70-79 years
(P < .01 for all results)
dentures more at risk of
developing attachment
Hirotomi and
97% 4 + mm attachment loss
Japan, 70 to 80 Years Old,
colleagues
48% 7 + mm attachment loss
Community-dwelling
loss.5 Clinicians note
abutment teeth > others
attachment loss resulting
poor periodontal health >
others
from gingival recession in
older adults more often
Chalmers and
66% edentulous
South Australia, Mean Age
colleagues
63% of sites with calculus
83.2 Years, Living in Nursing
than that resulting from
Homes
increased pocket depth,
Kiyak and
43% periodontal disease
Washington, 78 to 98 Years
and attachment loss with
colleagues
(high numbers of edentulous
Old, Living in Nursing Homes
gingival recession appears
residents)
to be more pronounced in
diabetic adults.8
usually would not provide flap surgery for a
Oral health in older adults who are institutionpatient such as this one, it is possible that thoralized often is worse than that in the general popough scaling and root planing with improved oral
ulation and involves increased prevalence of
hygiene could be used to manage the disease
edentulism and numerous unmet dental needs.
adequately.
As studies from Japan and Australia have shown,
this often is related to poor oral health status and
EPIDEMIOLOGY OF PERIODONTAL
poor mental health status, because increased
DISEASE IN OLDER ADULTS
caries and PD lead to increased tooth loss.5,9,10
This case report is typical of mild PD seen in older
These findings confirm those of a 1993 study6
adults, and PD is common in older adults
reviewed by Locker and colleagues,11 which also
1-6
throughout the world (Table). Net tissue
showed that a small percentage of subjects who
destruction (for example, bone loss) due to PD is
are institutionalized account for most attachment
cumulative with age. Since 52 percent of adults in
loss. Fifty to 75 percent of older adults had at
the United States have lost fewer than five teeth,
least one site with attachment loss of 2 to 3 mm,
most older adults are at risk of developing PD.
and new lesions were more common than were
Conversely, only 26 percent of Americans are
progressing existing lesions.11
edentulous and, therefore, not at risk of develSince general dentists are the primary oral
oping PD; in some states such as Hawaii and Calihealth care providers for most older adults, these
fornia, however, only 13 percent of the population
epidemiologic data suggest the need for general
is edentulous.7 In a study of older adults (mean
dentists to treat PD in most of these patients.
age, 85 years) living in rural Iowa, 91 percent had
Moreover, general dentists should work with the
PD, defined as at least one site with attachment
relatives of older adults who are institutionalized
loss of 4 mm or greater.2 However, only 15 percent
and administrators of local nursing homes to
1

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improve older patients routine oral hygiene and

reduce the high prevalence of PD and edentulism.

SYSTEMIC SEQUELAE OF PERIODONTAL

DISEASE IN OLDER ADULTS

ORAL SEQUELAE OF PERIODONTAL

DISEASE IN OLDER ADULTS

More subtle and sinister are the medical consequences of PD, in which PD might set the stage
for the patients experiencing diabetes mellitus,
respiratory disease, stroke and myocardial
infarcts. It also appears to be connected to other
chronic diseases such as osteoporosis, arthritis
and Alzheimers disease.
Diabetes mellitus. Diabetes mellitus results
from a derangement of glucose metabolism due to
decreased production of or response to the hormone insulin released by specialized cells within
the islets of Langerhans in the pancreas. Diabetes
exerts most of its effects on peripheral blood vessels, leading to either vascular proliferation or
impairment of blood perfusion by thickening of
the basement membrane,30 and it can lead to
blindness, peripheral neuropathy, nephropathy,
secondary infections, heart disease and PD. Type
2 diabetes is common in older adults, as is periodontitis; uncontrolled type 2 diabetes is thought
to be a risk factor for severe periodontitis.31,32
From a medical viewpoint, PD might influence
the course of diabetes. Evidence suggests that PD
is associated with poor glycemic control in prediabetic rats33 and treatment of PD improves
glycemic control in diabetic patients.34,35
Respiratory disease. Respiratory disease
(especially pneumonia) is a common cause of mortality in older adults. Since the oral cavity is proximal to and contiguous with the trachea, it is a
potential entry point for respiratory pathogens,
and teeth likely serve as an important reservoir
for these pathogens.36 Such pathogens colonize
oral biofilms found on surfaces such as dentures
or teeth. Once established in biofilms, pathogens
can be shed and aspirated into the lower airway,
increasing the risk of infection.37
People living in nursing homes or staying in
hospitals for extended periods have more exposure to pathogens, worse oral hygiene and worse
general health than do community-dwelling
adults (older adults who do not require assisted
living or nursing home care). As a consequence,
they are at more risk of experiencing respiratory
pathogen colonization than are communitydwelling people.38,39 There is evidence that the
genetic identity of respiratory pathogen isolates
recovered from bronchoalveolar lavage fluid of
elderly people who are hospitalized or institutionalized is the same as isolates from their dental

The high prevalence of PD in older adults should

be of concern because PD directly increases the
patients risk of developing root caries, as well as
tooth loss with resulting deficient masticatory
ability, nutrition and speech, which can worsen
the patients quality of life.
When combined with xerostomia, poor oral
hygiene due to arthritis and deficient oral care, as
well as uncontrolled dietary sugar consumption,
gingival recession and the resulting exposed root
surfaces, can lead to the development of extensive
root caries that often are a challenge to treat. As
studies have shown, this problem is common
around the world. The prevalence of root caries
has been reported to be 39 percent in older people
living independently in Japan,12 27 percent in
elderly people in Germany,4 29 percent in older
African-American people living independently in
North Carolina and 39 percent in older white
people living independently in North Carolina.13
These data emphasize the need for prevention, as
oral hygiene and fluoride treatment for patients
at risk of developing PD is more cost effective
than treating PD and root caries.14,15
However, older adults often do not receive routine preventive dental treatment, and PD often
progresses to the point at which bone loss leads
to tooth loss. Ultimately, patients who have few
teeth or teeth with advanced mobility experience
poor oral health16 and have difficulty chewing,
speaking or pronouncing words.17,18 Many
patients with mobile teeth avoid crunchy or
stringy foods, which often eliminates meat, bread
and vegetables from their diets.19 Insufficient
intake of nutritious foods can lead to malnutrition, with resulting unintentional weight loss,
fatigue and poor general health.20 Nutritional
deficiency can exacerbate PD, with gingival
recession leading to exposed crown margins,
stained roots and loss of interdental papillae.21
Although dental appearance usually is less
important to older adults than younger adults,22
together with functional impairment and diminished general health, it might explain the association between tooth loss and avoidance of
socialization, as observed by Jones and colleagues.23 PD almost certainly decreases the
quality of life for older adults.24-29

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plaques.40 These studies show that dentists must

consider dental plaque to be an important reservoir of respiratory infection.
Since the oral cavity likely serves as a reservoir
for respiratory pathogens in patients who are
institutionalized, oral hygiene interventions may
reduce the rate of oral colonization by respiratory
pathogens and, subsequently, the patients risk of
developing pneumonia. Azarpazhooh and Leake41
conducted a systematic review in which they
found that improved oral hygiene and frequent
professional oral health care reduced the progression or occurrence of respiratory diseases among
elderly adults who were at high risk of developing
respiratory disease and were living in nursing
homes, especially those in intensive care units.
Simple oral decontamination using topical antimicrobial agents such as chlorhexidine gluconate
both with and without mechanical plaque control
appears to be effective in substantially reducing
the rate of pneumonia in vulnerable populations.42
Vulnerable populations include patients who have
dysphagia, feeding problems and poor functional
status.43 This finding has prompted some hospitals to implement formal, organized oral hygiene
programs to reduce the risk of patients developing ventilator-associated pneumonia (VAP). The
Center for Disease Control,43 the American Thoracic Society44 and the Infectious Disease Society
of America44 also have recognized that poor oral
health is a possible modifiable risk factor for VAP.
While chronic obstructive pulmonary disease
(COPD) commonly is associated with environmental factors such as smoking, epidemiologic
studies suggest an association between PD and
COPD.45,46 Although there is no evidence to date of
a causal link between poor oral hygiene, PD and
COPD, a three-year study of community-dwelling
older adults found that gingival index and loss of
attachment were significantly better in participants with normal pulmonary function than in
those with an airway obstruction after adjusting
for age, race, sex and field center location.46 While
the biological relationship between COPD and PD
is uncertain, it might be similar to the relationship of pneumonia and PD, with aspirated proinflammatory cytokines and enzymes being key
players. Since PD features increased salivary
proinflammatory cytokines and enzymes,47 this
might explain the improved pulmonary function
seen in the three-year COPD study.46
Cardiovascular disease (CVD). Oral hygiene
and frequent professional oral health care also
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might be good for heart and brain health in the

long term. There has been interest in the potential effect of periodontal inflammation on the
process of atherosclerosis and its sequelae. Epidemiologic studies have found a stronger association between PD and CVD or stroke, especially in
younger male subjects.48,49
In a panoramic radiograph study of 60- to 75year-old subjects, researchers found a correlation
between alveolar bone loss and an increased risk
of experiencing CVD.50 However, this association
was diminished when they accounted for the subjects smoking histories. This contrasts with a
radiograph study in which researchers associated
alveolar bone loss, increased pocketing and clinical attachment loss with increased risk of experiencing CVD in subjects younger than 60 years,
even after adjusting for smoking and diabetes.51
PD-induced gingival recession and subsequent
root caries also might lead to an increased risk of
experiencing cardiac dysrhythmia.52 Although PD
may not be a major risk factor for some older
adults,53 investigators in one study found 1.5-fold
increased odds of experiencing atherosclerosis
and coronary heart disease in older adults who
had experienced both periodontitis and tooth loss,
after adjusting for the traditional risk factors of
heart disease.54
Stroke. One danger of atherosclerosis is an
increased risk of experiencing stroke, and PD
might be associated with this increased risk. For
example, a case-control study found that men
younger than 60 years who had severe periodontitis had a 4.3 times higher risk of experiencing
stroke than did patients in the same age group
who had mild or no periodontitis.55 Likewise, alveolar bone loss was associated with an increased
risk of experiencing stroke in the panoramic radiograph study, although the subjects smoking histories confounded this association.50 According to
both studies, PD-related risk of stroke seems to
be higher in younger people, which probably indicates that other risk factors such as smoking
become more important in older patients. In addition, stroke risk might be influenced by survivor
bias, in which patients who are less susceptible
to PD-mediated stroke live longer. As with all the
association studies mentioned, caution must be
exercised in interpreting statistical association as
evidence for possible cause-effect relationships.
However, the possibility that poor oral health
influences systemic health is interesting since
many of the traditional risk factors for CVD and

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ORAL HEALTH GOALS

Overriding Issues

Modifiable Risk Factors

1. Life expectancy

1. Tobacco use, plaque control

2. Financial commitment

2. Controllable medical

3. Permanent medical conditions

conditions (for example,

(for example, intravenous

diabetes)

bisphosphonate treatment)

3. Active oral disease

4. Biological issues (for example,

4. Occlusal factors

gingival biotype, bone quality)

5. Periodontal factors

5. Functional needs
6. Esthetic needs

bone loss and self-reported osteoporosis.65 Some studies indicate

that estrogen replacement therapy
for osteoporosis prevention in
women also reduces the risk of
experiencing tooth loss,66,67 but
estrogen has not been used as a
potential agent to reduce tooth loss
in older women.
GUIDELINES FOR
THE TREATMENT
OF PERIODONTAL DISEASE
IN OLDER ADULTS

TREATMENT PLAN

Periodontal infection and inflammation interact with many other

Figure 2. Treatment plan considerations for older adults. Sources: Ellen72 and
ailments experienced by older
Holm-Pedersen.73
adults, and they likely diminish
oral function, reduce quality of life, imperil nutristroke such as smoking, being male, sedentary
tion and increase the patients risk of developing
lifestyle, obesity, hypertension and dyslipidemia
several chronic systemic diseases. Since the conare not easily modifiable. In contrast, provision of
sequences of PD are severe, general dentists need
or improvement in oral care might prove to be an
to help older adults preserve their periodontal
easily modifiable risk factor that could help
health.
reduce the incidence of the most common causes
Most evidence indicates that older adults genof mortality in this society.
erally respond to periodontal therapy similar to
Osteoporosis, arthritis and Alzheimers
they way younger adults do.68 As patients age,
disease. PD also might affect older adults
however, the presence of multiple chronic medical
through potential interactions with Alzheimers
conditions and polypharmacy becomes a condisease, arthritis and osteoporosis. In a longitucern.69 Clinicians should review carefully the
dinal study, Ship and Pucket56 found that subjects
patients medical history and prescribe pharmawith Alzheimers disease had diminished salivary
ceuticals judiciously to prevent unwanted drug
flow and poorer oral health, and they recominteractions. Some medical conditions such as
mended aggressive prevention of oral diseases as
Alzheimers disease and arthritis inhibit plaque
long as possible to maintain quality of life.
control, so clinicians should provide individualSevere arthritis also can diminish quality of
ized oral hygiene instructions with appropriate
life for patients, and alveolar bone loss has been
aids or caregiver involvement; however, no clinassociated with arthritis.57 Bartold and colical trial data comparing plaque control strategies
leagues58 hypothesized that there is a common
in patients with debilitating medical conditions
dysregulation of proinflammatory pathways for
have been reported. Friedlander and colleagues70
both arthritis and periodontitis, and they strongly
suggested evaluating patients who have arthritis
provide suggestions specific to Alzheimers disfor periodontitis. Unfortunately, a clear relationease. Receiving repeated personalized oral
ship between PD and arthritis has not been
hygiene instruction in a group setting also might
established, owing to conflicting studies.59-62 Since
help patients achieve better plaque control.71
arthritis often limits manual dexterity and oral
With increasing dependence or morbidity, howhygiene is key in preventing PD in patients with
ever, controlling disease progression might be a
arthritis, the use of powered rotating-oscillating
more realistic goal.
toothbrushes and antiseptic or fluoride mouthIn general, treatment is influenced by the
rinses has been recommended to improve oral
patients overall health, functional and esthetic
hygiene.63,64 However, clinicians need to emphaneeds. Once the clinician determines the patients
size to patients the importance of achieving good
oral health goals, he or she should identify overmechanical plaque control using appropriate aids.
riding issues and modifiable factors72,73 (Figure 2).
PD is associated significantly with alveolar
The treatment plan should address the modifiable
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31S

risk factors, including risk factors for disease progression, within the limits posed by overriding
issues. No treatment is contraindicated per se,
which allows for the reliable use of implants in
elderly people to replace teeth lost due to caries
or PD.74
Dentists should give special consideration to
patients who are frail or institutionalized if they
cannot maintain oral hygiene. In such cases, nonsurgical periodontal therapy might be the only
feasible option.75 Dentists can use chlorhexidine
as an adjunct for oral hygiene if home care is poor
in patients who are debilitated,76 but it may not be
sufficient by itself to preserve oral health.
CONCLUSIONS

Older adults often have a variety of chronic medical conditions and take many medications. At the
same time, they often have poor oral hygiene and
PD, which may promote additional oral health
problems such as root caries and exacerbate systemic complications related to poor nutrition and
progressive chronic systemic diseases. Therefore,
dentists should make every reasonable effort to
prevent PD progression as the case report demonstrates. Good communication between patients
general dentists, primary physicians and medical
specialists is essential for managing the care of
patients who have medically complex conditions.
General dentists should be able to manage mildto-moderate PD in older patients, since treatment
is similar for all adults with mild-to-moderate
forms of the disease. Since the understanding of
PD is evolving, general practitioners in 20 years
likely will have many more tools available for
diagnosing and treating PD.77 Perhaps one day
this might include regenerative gene therapy procedures that will be applied as easily as local
anesthetic is today.78
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