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Dental diseases

There are two main types of dental disease that can affect the elderly:

  • Gum (Periodontal) Disease
    Gum disease can cause inflamed and bleeding gums, gum recession (gum tissue is reduced such that the roots of the teeth become exposed), loose teeth and bad breath. It is caused by the build-up of dental plaque (a combination of food debris and bacteria). Plaque leads to gum disease if it is not removed by daily efficient brushing and flossing. This gum disease is known as periodontitis.
  • Tooth Decay (Dental Caries)
    When a person takes in sugary food and drinks, it leaves dental plaque on the teeth. Bacteria in the plaque feed on sugar and produce acid. When proper dental care is not done, this acid produced by dental plaque attacks the tooth and eventually causes decay in the tooth. If there is gum recession at the same time, this increases the chance of decay at the necks of teeth. To prevent tooth decay, it is important to keep the mouth clean.

Both gum disease and tooth decay cause discomfort or pain and can lead to infection. Other problems that are caused by poor dental care include:  

  • Poor nutritional status, as a result of food not chewed thoroughly
  • Low self-esteem, not feeling good about oneself
  • Difficulty in improving control on diabetes
  • Increased risk of pneumonia, especially in elderly with swallowing problems, which can lead to increased hospital stays
  • Worsen confusion associated with elderly with dementia, when there is pain and infection

General tips on good dental care:

  1. Brush the teeth twice daily
  2. Care for dentures through the following:
    • Remove dentures and rinse with plain water after meals
    • Brush dentures thoroughly before bedtime and soak them in a denture cleanser at night
    • Brush dentures using a soft toothbrush. DO NOT use toothpaste as it can damage the denture. Food remnants should not be left on any surface of the denture
    • Use a soft toothbrush to clean the gums, tongue and roof of mouth
    • DO NOT wear dentures to sleep as it will cause unhealthy bacteria to build up in the mouth

Visit a dentist regularly to get timely advice on:

  • How to brush properly
  • Types of toothbrush to use e.g. manual vs electric, interdental brushes, etc.
  • Types of toothpaste to use, whether mouthwash is necessary
  • How to brush for your loved one, if you are a caregiver
  • Management strategies to brush properly for older adults with behavioural issues e.g. dementia
  • Signs to look out for to determine oral health problems

Note: In older adults with difficulty brushing, either get them to brush by themselves first and have a caregiver check and brush again later, or have the caregiver brush their teeth for them. Take into account their feelings as much as possible; try to maintain their ability to perform independent tasks for as long as possible.

Dental care in older adults

Why is dental care important for the elder?

Dental care is important for everyone, even if your loved ones have few teeth remaining, or no natural teeth left.

Maintaining daily oral hygiene brings benefits to quality of life in the elderly – it increases self-esteem, enhances social integration and improves absorption of nutrients. Eating is more enjoyable with a healthy mouth, when there is no pain or infection in the teeth and gums.

Challenges in maintaining good dental care in the elderly

Some elderly persons may have fewer teeth than before, or no natural teeth left. As such, they may feel that it is not important to perform oral hygiene on a daily basis.

The elderly may have difficulties maintaining oral health because of:

  • Poor eyesight
  • Conditions affecting movements of the hand, for example, osteoarthritis, Parkinson's disease
  • Conditions affecting their mood, for example, dementia, depression
  • Conditions affecting their mobility to get to the toilet basin, for example, stroke

A lack of good oral hygiene can increase the likelihood of dental diseases in the elderly.

Dental health in persons with dementia

As dementia progresses, the person with dementia may forget how to brush his or her teeth or forget why it is important. As a caregiver, you may have to assist or take a more hands-on approach. Persons with dementia are susceptible to dental problems because of:

  • Reduced saliva
    Saliva is essential to maintain a healthy mouth and to prevent the onset of dental decay and other oral lesions. Saliva acts as a lubricant and also cleans the mouth and teeth. Lack of saliva can thus lead to a build-up of plaque and increase the risk of dental decay, gum disease and infection. A dry mouth can also cause dentures to become loose and uncomfortable. A moisturising mouthwash may help with dry mouths as well.

    Saliva production decreases as a person ages. In addition, some medications may reduce the production of saliva by salivary glands.

    Denture fixatives and artificial saliva (a fluid to lubricate the mouth) can help some people with denture problems.  Frequent sips of water throughout the day, especially at mealtimes, will help.
  • Medications
    Certain medications can cause involuntary repetitive movements of the jaw and tongue, making it difficult to wear dentures and may cause wearing down of teeth. In some cases, these movements will continue after the drug is stopped. A dentist may be able to advise on what can help, and how best to ensure that your loved one is comfortable.
  • Reduced oral care
    Physical limitations may affect abilities to maintain their oral health.

What to look out for?

Behaviours that may suggest your loved ones are experiencing dental problems include:

  • food refusal
  • refusing to wear dentures
  • facial expressions such as grimacing
  • increased restlessness, agitation, shouting
  • disturbed sleep
  • aggressive behaviour

Tips on toothbrushing for persons with dementia

  1. Mild dementia stage
    Your loved one may find it easier to use an electric toothbrush or a toothbrush with an adapted handle to improve their grip.

  2. Moderate to severe stage

    • Change to an electric toothbrush or a toothbrush with larger handle to improve grip 
      You can modify the toothbrush handle by putting the handle through a tennis ball. Try different types of toothbrushes until you find the best choice

    • Give short and simple instructions 
      Break down instructions step by step. E.g. "Hold your toothbrush." "Put toothpaste on the brush." Then, "Brush your teeth."

    • Use a "watch me" technique and show your loved ones how to brush their teeth 

    • Put your hand over your loved ones' hand to guide them in brushing 
      Give your loved one the toothbrush with toothpaste already on it and put your hand over theirs to start the up and down brushing movement to help get started. It may be easier to stand behind your loved one while doing this.

    • Postpone brushing to a later time if your loved one is not cooperative. 
      Anti-plaque mouth wash can be helpful in preventing gum disease—but ONLY if it won't be swallowed.

My loved one with dementia may swallow toothpaste or mouthwash. What can I do?

Safer options for persons with moderate to severe dementia include:

  1. Fluoride free toothpastes 
  2. Alcohol-free, chlorhexidine gel to clean teeth 
    • Use your fingertip or a very soft toothbrush to apply the gel to the teeth
  3. Any commercial alcohol-free chlorhexidine mouthwash 
    • do not gargle mouthwash
    • instead, dip toothbrush in mouthwash, shake off excess and brush teeth
  4. Sodium bicarbonate solution 
    • mix 1/2 teaspoon of sodium bicarbonate in 200mL of water, dip toothbrush in mixture, shake off excess and brush teeth
  5. Brush teeth with toothbrush and water only 
    • mechanical brushing is more important than the pastes/mouthwash we use

More retail items for dental care in older adults can be purchased at Dental Clinic (Clinic 6B, Level 6, TTSH Medical Centre. 

The journey to a brighter smile

Oral health plays a vital role in the overall well-being of a person.

Many people may have the misconception that all forms of dental treatment are painful and will tend to neglect their oral health. With new approaches to dental treatment and multidisciplinary care, dental treatment has transformed the perception of many patients as the whole experience can be made more comfortable and pleasant. Read on to find out more about a patient's oral health journey.


Oral health encompasses the daily care and maintenance of the oral tissues. This comprises two components: the hard tissues and soft tissues. Teeth and bone make up the hard tissue component, while the lips, cheeks, gums and tongue make up the soft tissue component. Teeth are made up of three main layers: enamel, dentine and pulp (Figure 1).

Without proper care and maintenance, oral neglect can lead to a myriad of problems such as tooth decay and gum disease. A root canal infection will occur if tooth decay progresses to the pulp chamber and swellings can develop with abscess formation (Figure 2).

Tooth decay can be prevented by reducing the frequency of sugar intake while proper tooth brushing technique with a daily flossing regimen may prevent gum inflammation called gingivitis. Individuals with increased risk of dental decay may supplement their daily oral hygiene routine with the use of fluoride mouth rinses.

Fearful no more

Ms Elaine Ou was first presented to the Tan Tock Seng Hospital (TTSH) Dental Clinic in early 2009 with the hope of realigning her teeth prior to her wedding day. She had been referred to Dr Vivien Tan Hui Ling, the Head and Senior Consultant of Dental Clinic by her family members.

She had been reluctant to seek dental treatment earlier as she had an innate fear of the dentist from her primary school days. She had overcome her fear for the initial visit with the encouragement of her sister, who had also undergone treatment with Dr Vivien several years earlier.

Initial findings

Relevant radiographs were obtained and diagnostic casts were prepared. The treatment options available were discussed with Elaine to provide her with a better understanding of the commitment required for treatment to proceed. Although the timeline was challenging, both Elaine and Dr Vivien decided to embark upon the proposed plan.


Circumstances were compounded by the fact that Elaine was at a higher risk of developing dental caries.

An atypical extraction scheme was decided upon whereby her grossly decayed upper left canine tooth was removed as very little tooth structure was remaining for the tooth to function even with prosthetic restoration.

Three other premolar teeth and her wisdom teeth were also removed under general anaesthesia. Concurrent removal of the teeth under general anaesthesia expedited the commencement of braces without compromising Elaine’s comfort levels.

Clinical course

The molars were banded and activation began.

Elaine was compliant with her six-weekly reviews as her wedding day drew closer. On 8 January 2010, the eve of Elaine’s wedding, she had the orthodontic brackets removed and tooth-coloured composite resin restorations placed on her upper front teeth to achieve desired aesthetics for her special day. The bride was, without a doubt, the most beautiful person at the wedding.

Elaine had returned on 22 January 2010, after her honeymoon, to have her orthodontic brackets replaced and treatment continued. Upon completion of her braces treatment in April 2011, Elaine had further tooth-coloured composite resin restorations placed before commencing on definitive crowns on her upper teeth.

Dr Ang Kok Yang, the dental officer in-charge of Elaine’s case together with Dr Vivien, had prepared five upper teeth to receive crowns to provide adequate protection against fracture during function. Retainers were subsequently fabricated to hold the teeth in their new positions. Elaine’s new smile had warmed many hearts at the end of treatment. Her whole outlook on dentistry had been changed for the better. When she returned for an annual review in December 2012, she had progressed to the next stage in life: motherhood. The arrival of her little bundle of joy, a new baby girl, made her smile even wider than ever. This time, she no longer dreads her dental visits.

5 Quick FAQs for a better health!

Do our loved ones with no teeth or on tube feeding need oral hygiene?

Definitely. Studies have shown that for people on tube feeding, normal bacteria in the oral cavity eventually get replaced by bacteria that can cause serious lung infections.

What happens when you neglect an elderly's oral hygiene?

Poor oral hygiene often leads to 2 main types of dental diseases known as Gum Disease and Tooth Decay. Both of these can cause discomfort or pain and can lead to infection. The pain and infection from these dental diseases can further worsen the confusion associated with dementia.

What are some problems associated with poor oral hygiene care?

Problems associated with poor oral health can be very detrimental. They include, negative effects on self-esteem, poor nutritional status, difficulty in improving diabetic control and an increased risk of pneumonia (especially in elderly with swallowing problems) – All of which leading to an increased incidence of hospitalisations and mortality among the elderly.

What are signs of oral discomfort among elderly patients?

Some common behavioural indicators among the elderly include:

  1. Food refusal
  2. Refusing to wear dentures
  3. Facial expressions such as grimacing
  4. Increased restlessness, agitation, shouting
  5. Disturbed sleep
  6. Aggressive behaviour

What are some ways to prevent gum disease among elderly patients?

To simply put: brush teeth twice daily, ensure that dentures are properly cared for & visit a dentist regularly. Anti-plaque mouth wash can be helpful in preventing gum disease — but ONLY if it won't be swallowed.

More retail items for dental care in older adults can be purchased at Dental Clinic (Clinic 6B, Level 6, TTSH Medical Centre). 

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