Oral Health Problems in the "Second Fifty"
The relations between oral and general health are dynamic. When oral health is compromised, overall health and quality of life may be diminished.16,33,45 On the other hand, the rewards of good oral health are not insignificant. The optimal function of the oral cavity depends on the integrity of the dentition and supporting structures. The five most serious oral functional impairments of the older adult are (1) perioral and oral mucosal tissue pathologies (cancers and precancerous formations); (2) severe, untreated caries and periodontal diseases; (3) tooth loss resulting from oral diseases and conditions; (4) oral expressions of systemic diseases and side effects from medications; and (5) orofacial pain (including dry mouth and pain of undiagnosed origin). Reduced oral function is usually associated with the occurrence of a combination of these impairments.
The health of the oral cavity—that is, the teeth, oral soft tissues, underlying bone, neurosensory apparatus, immune system, and glandular mechanisms—is critical to chewing, tasting, swallowing, and speech, as well as to adaptation to dentures, if worn. It also contributes to self-esteem, nutrition, facial esthetics, and protection from systemic infection and injury. Self-esteem and social function may be significantly diminished by chewing disorders, which are common among the elderly. Moreover, difficulties with chewing are most frequently associated with an urgent need for care but are rarely reported as morbidity.13,16,45,46
Fortunately, the oral health, oral hygiene practices, and dental service utilization of older age groups have improved over the past several decades. Moreover, continued improvements are projected as the cohorts that swell the ranks of the older generations include a greater number and larger proportion of better educated, more affluent dentate individuals than ever before.7,15 An older individual who retains his or her own teeth, however, is at continued risk for oral diseases. An estimated 40 percent of older Americans during the next two decades will constitute an oral special needs category based on complex health problems and functional status.41 The chronic and progressive nature of oral diseases may result in tooth loss and disability. Prevention and early intervention are therefore critical, and impairments that are not addressed early have a greater likelihood of becoming disabling.
There is no epidemiological evidence to suggest that tooth loss or specific oral diseases are a necessary concomitant of the aging process, nor do all persons over age 50 fall into a single descriptive group in terms of oral health.7 Rather, it appears that there is a great deal of heterogeneity in the older population, depending on lifetime oral health experiences, related medical conditions, and social and economic status.
All adults enter their second 50 years at risk for multiple oral diseases and conditions. At age 50, 11 percent have lost their teeth, and the remainder have an average of only 22 teeth. Among those with teeth at age 50, 5 percent have untreated coronal caries, 42 percent have untreated root caries, 40 percent have gingivitis, and 17 percent have periodontitis.43 Salivary dysfunction apparently begins to increase in prevalence at this age. Individuals beyond age 50 exhibit rising levels of dysfunction through increased tooth loss, root caries, periodontal diseases, pain, and oral complications of general systemic conditions.
Physical impairments of the oral cavity most often affect chewing, swallowing, phonetics, and social functions. The nature of an individual's impairment, combined with various other risk factors, determines whether the impairment will become disabling or handicapping. The transition to disability and handicap, however, is in large part dependent on appropriate self-care and professional preventive care for older adults.32 Strategies must be developed to diminish oral diseases and injuries and to remove barriers to self-care and professional services. Descriptions of the major burdens faced by the older population, including prevalence data, are provided below.
Perioral Tissue and Oral Mucosal Tissue Pathologies and Oral Cancer
Numerous oral mucosal conditions are prevalent among older adults. Sometimes they are secondary to systemic disease; at other times they occur as a result of side effects of medication, ill-fitting dentures, and substance abuse (e.g., tobacco and alcohol).10 In a series of screenings conducted between 1957 and 1972 among older white adults in Minnesota, 10 percent had at least one oral lesion that was unusual enough to be recorded. In this population the prevalence of leukoplakia, a precancerous condition, was 29.1 per 1,000, and the prevalence of oral cancer was 0.9 per 10,000.11 Herpes virus, papilloma, and pemphigus are also common among older adults.
Oral cancers are life threatening and cause severe handicaps. In the United States each year, 9,400 persons die of oral cancer, and some 30,000 people develop the disease. Although oral cancers constitute only 3 to 4 percent of all cancers in the United States, only one-half of the affected population are alive five years after diagnosis.1 Most survivors suffer serious functional impairment and have an exceptionally high risk of subsequent primary and secondary malignancies; thus, they are at great risk for further disabilities or handicaps. The prevalence of oral cancer is greater among men than women and increases with age, with the great majority of cases occurring after the age of 40.
The long-term impact of tobacco use and alcohol on the condition of teeth and the development of soft-tissue lesions—specifically, oral cancer—are more apparent in older individuals. It has been estimated that 75 percent of oral cancers can be attributed to using tobacco and drinking alcohol. The risk of oral cancer for tobacco users is 4 to 15 times greater than for nonusers, increasing with both duration and frequency of tobacco use. Individuals with lower educational levels or infrequent dental visits are also more likely to suffer from soft-tissue lesions.10
Dental caries contribute directly to impairments through pain and discomfort; they contribute indirectly through tooth loss. Severe and persistent caries can become disabling or handicapping. Dental caries in older adults are manifest primarily as (1) cervical caries associated with plaque accumulation at the gingival margin; (2) root caries associated with gingival recession; (3) secondary phenomena to medical conditions or pharmaceutical challenges; and (4) recurrent
caries adjacent to restorations on coronal or root surfaces.7,24 The etiology of root caries, which are essentially limited to adults, may involve physical and oral health as well as behavioral and social factors.9
It appears likely that the coronal caries process is the same regardless of age. Most older adults are at relatively low risk of developing caries. As with children, those who are susceptible usually exhibit high levels of the disease.24 Once caries are present, the contribution to tooth loss is mainly a function of whether the lesion is treated and, if so, how many times the restoration requires replacement.
In 1985-1986, adults aged 65 and older who attended senior centers had an average of 20 decayed or filled coronal tooth surfaces, with about 92 percent of these surfaces being filled.43 In working adults, aged 50-64, about 95 percent of the surfaces had been filled. Additionally, as individuals age, there is an increase in the prevalence of root surfaces caries.5,9,24,43,47 In the 50-to-54 age group, about 42 percent of individuals have root surface caries. This prevalence increases steadily to 54 percent by ages 60 to 64 in the working population. Among dentate older adults at senior centers in 1985-1986 the prevalence of root caries increased from 64 percent in the 65-to-69 age group to 71 percent in the 75-to-79 group. Only about half (54 percent) of these root surfaces were filled.43
The caries process reflects the interaction of four basic risk factors: a susceptible tooth surface, the presence of a sufficient number of cariogenic microorganisms, inadequate fluoride exposure, and ingestion of a caries-conducive diet. Other factors conducive to dental caries include a history of high caries prevalence, reduced salivary flow, altered salivary composition, gingival recession, and poor oral hygiene. Certain systemic conditions, medications, psychiatric disorders, and social or personal conditions may potentiate some of these risk factors.
Periodontal diseases are a function of a selective microflora active in a conducive environment. The severity of periodontitis is measured by the magnitude of gingival inflammation, pocket depth, and loss of periodontal attachment. Loss of attachment, which is the main predictor of tooth loss from periodontal diseases, is of major concern if it is extensive and progresses more rapidly than expected.44
Severe periodontal diseases contribute to oral dysfunctional impairment directly through gingival bleeding, pain, and discomfort,
and indirectly through tooth loss. Depending on the level of involvement, periodontal diseases can be disabling or handicapping. Less severe periodontal disease may lead to social dysfunction as a result of bad breath.
The prevalence and severity of periodontal diseases increase with age, yet most individuals have signs of destructive disease in only a few sites at periodic intervals.7,43,44 The higher prevalence and severity of periodontal diseases among older persons may not be the result of enhanced susceptibility but rather may reflect the accumulation of disease over time.44 These diseases are prevalent in otherwise healthy individuals, although certain systemic conditions (e.g., diabetes) appear to be associated with more severe types of periodontal diseases.
Ninety percent of individuals aged 65 and older need some type of periodontal treatment; 15 percent need complex treatment.27 The periodontitis of persons who have retained their teeth to old age is often of the type that, at any given site, progresses slowly.
Other Oral Conditions
Trauma is a key factor in tooth loss, and although it is usually associated with activities of youth, it is not uncommon for older adults as a result of automobile accidents, falls, or biting into food. Traumatic injuries and jaw fractures have immediate and long-term consequences. Injured teeth may be loosened or displaced, or they may be broken (exposing dentine or pulp) or avulsed. Like injuries to other parts of the body, injury to the orofacial area can have social-psychological side effects. Unlike injuries to other parts of the body, injuries to teeth are unique in that healing does not follow the usual reparative processes.
Certain diseases of the salivary glands, including local inflammatory diseases and Sjogren's syndrome, are more common in older than in younger adults.36 Acute suppurative sialoadenitis, as well as chronic recurrent sialoadenitis, is more common in older, seriously ill, debilitated patients. The prevalence of Sjogren's syndrome—lymphoepithelial lesions—is second in prevalence only to rheumatoid arthritis among the connective tissue diseases, with onset typically in women 40 to 60 years of age. There is some indication that submandibular saliva and possibly minor gland secretions may be affected by aging.36
Oral symptoms of hypofunctional or nonfunctional salivary glands are unpleasant and painful and affect speech, taste, chewing, and swallowing. Xerostomia (dry mouth), a frequent side effect of medications,
Oral conditions that were, in the past, considered stereotypical of aging are now beginning to be seen in a different light. Research does not support a consensus regarding the causes of diminution of stimulated parotid fluid output, structural changes in epithelium, atrophic change in oral mucosa, and generalized reductions in taste acuity and perception. Evidence suggests that other factors, such as polypharmacy, inadequate nutrition, or systemic diseases may be the precursors of these conditions and not age per se. Other age-related changes in taste, olfaction, and oral sensation, such as touch, temperature, and pressure sensibility, have been observed but have not been well described or documented.34
Because tooth loss is the sequela of caries, periodontitis, and trauma, it is a general indicator of the amount of severe oral diseases experienced by an individual or a population.49 The relationship between tooth loss and oral diseases, however, is complicated. Tooth loss also reflects aspects of the dental delivery system that are not disease related—for example, the cost, access to, and utilization of dental services, limitations of existing technology, and variations among treatment options offered and chosen in the dentist/patient interaction. A population's level of tooth loss is therefore a reflection of cultural values as well as the availability, accessibility, cost, and appropriateness of preventive services and treatment.
Despite a steady decline in the rate of edentulousness (toothlessness) over the past several decades, 55 percent of individuals aged 85 or older were edentulous in 1986.39 Edentulism decreases in the younger age groups of the ''second 50": 44 percent of those aged 75 to 84, 30 percent of those aged 65 to 74, 22 percent of those aged 55 to 64, and 12 percent of those aged 45 to 54. There appears to be both a cohort and an aging effect in this trend. Thus, overall edentulousness will be considerably reduced, without any intervention, over the next few decades. Edentulism continues to be more prevalent among older persons below the poverty level, however, and among those with fewer years of education.39
Edentulous people often face severe psychological, social, and physical handicaps. Among older adults, loss of natural dentition can complicate systemic health problems and may interact adversely with certain behaviors. Even when missing teeth are replaced with
well-constructed dentures, there are limitations in speech, chewing ability, and quality of life. As many as 60 percent of denture wearers have denture-related problems, including soft tissue lesions.28
Functional impairments are not limited to complete loss of teeth. Tooth loss increases after the age of 35 and increases considerably in the over-50 age groups.37 Replacement of missing teeth is necessary to retain an adequately functioning dentition. Some prosthodontic treatment is needed by 27 percent of noninstitutionalized older adults, and the lack of replacement represents a considerable disability.28 Prosthodontics treatment need is associated with socioeconomic status and race,4,23,26 in part reflecting the expense of bridges, partial dentures, and other prosthetic services.
Oral Expressions of Medications, Systemic Conditions, and Diseases
Medications for age-related systemic conditions (e.g., congestive heart failure, diabetes, depression, sleep disturbances, chronic pain) have been shown to have direct and indirect effects on oral health status and dental treatments.29 Approximately 120 physical or mental diseases manifest symptoms in the oral cavity or affect oral function. The prevalence and burden of most of these conditions increase with age.29
Studies of a rural Iowa population revealed that more than 75 percent of a population aged 65 and older took medications that could affect oral health or dental treatment. Commonly used drugs affect blood clotting and cause oral ulcerations or sloughing of soft tissue. Others interface with oral health care. About one-fourth of these older adults take muscle relaxants and medications for anxiety, which can interact adversely with drugs commonly used in dental surgery for sedation and pain relief. Drugs commonly used by older persons for cardiac conditions can interact adversely with local anesthetics containing epinephrine. In addition, broad-spectrum antibiotics, medications for diabetes, systemic corticosteroids, phenytoin for convulsions, nifedipine used for cardiovascular diseases, medications for angina and congestive heart failure, and antipsychotic medications may be associated with abnormal healing, predisposition to infection, overgrowth of gingival tissue, inability to tolerate long, stressful appointments, and abnormal oral-facial movements.34
Iatrogenic causes of salivary gland dysfunction are significant. About one-half of the older individuals in the Iowa study took drugs that may contribute to xerostomia (e.g., antihypertensives, antihistamines,
decongestants, diuretics, painkillers, and tranquilizers). Moreover, ionizing radiation and chemotherapeutics, common therapies for cancer in older adults, can severely affect the salivary glands and the oral mucosa and may result in radiation caries.
Aging diabetic patients in particular are vulnerable to oral infections and impaired healing, which may lead to chronic destructive periodontal disease and other oral problems.29 Psychoses, affective disorders, and sleep disturbances, on the other hand, may affect the patient's willingness or ability to perform appropriate oral hygiene or seek dental services, thus affecting oral health, speech, or swallowing.29 Neurological problems, including stroke, Alzheimer's disease, and Parkinson's disease, can adversely affect oral functions.
Slower movements, reduced agility, arthritis, Alzheimer's disease, impaired vision and hearing, urinary dysfunction, and vascular insufficiency may all undermine the ability to follow recommendations for self-care. They may also make it impossible for an older individual to visit a dental office or to tolerate lengthy visits. Finally, diet, particularly fermentable carbohydrates, may have a considerable impact on oral conditions and root caries.
Orofacial pain is a condition of great concern in that 20 to 25 percent of all chronic pain problems are localized in this region. Chronic and acute pain can adversely affect oral functions, which ultimately has a significant impact on general health and quality of life. These effects appear to be substantial for older adults; although the epidemiology of orofacial pain is not well documented, chronic and acute pain generally, and in the orofacial region specifically, appear to be more prevalent in the elderly. Within the oral region, pain related to "dry mouth," temporomandibular joint dysfunction syndrome, generalized orofacial pain, various arthroses, and oral cancers are known causes of chronic pain.
Based on current projections, it is assumed that each succeeding cohort to enter the "second 50" will have more teeth and greater expectations regarding tooth retention. This dramatic change in the nature of oral health for aging individuals creates new challenges for research, education, and clinical care. In spite of major successes in dental research, treatment, and prevention over the past several decades, oral diseases of all kinds remain among the most costly of
U.S. health problems (the national bill for dental services in 1988 was $30+ billion).40 With the projected increase in the number of dentate older adults, ability to pay may become an increasingly critical factor.51 Dentate older adults are seeking and receiving complex, expensive dental services at a proportionately greater rate than younger adults.19 Although preventive services are generally less expensive than restorative procedures, they nevertheless represent a basic cost in personal health care services. Considerable restorative work (secondary prevention) will be needed by upcoming cohorts to maintain a functional dentition; as a result, the total absence of insurance or prepayment mechanisms, and the failure of many reimbursement systems to acknowledge and support preventive services, may create significant barriers to regular use of dental services in the over-50 population.15,19
Many direct risk factors for common oral diseases of older adults are known. The reduction of those factors, or their actual elimination, is possible through appropriate preventive self-care, elimination of high-risk behaviors, professionally provided preventive, diagnostic, and therapeutic care, and a supportive environment.
Prevention of Oral Cancer
At present, there is no consensus regarding secondary prevention of oral cancer. Oral cancer screening procedures have yet to be tested for sensitivity and false-positive rates; there is also concern that a complete oral exam is too impractical for physicians to perform with every periodical visit.48
All high clinical suspicions of oral cancer indicate the need for biopsy, regardless of other diagnostic tools. Most oral lesions are detected when they are in an advanced state and are easily seen owing to their large size. Because the probability of developing oral cancers varies by location and behavior, early detection of oral cancers, when lesions are smaller, depends on an acute sense of the high-risk areas of the mouth and the connection between risk behaviors (e.g., smoking and drinking) and the locus of the lesions.
For high-risk groups, a stronger consensus exists regarding primary and secondary prevention. Good evidence suggests that an independent and synergistic risk exists for oral cancer as a result of smoking and excessive alcohol use. Tobacco chewing has also been linked to oral cancer. Patients who are at risk because of these behaviors should be counseled against them by their health care providers. These high-risk patients should be screened during periodical health exams and should be examined annually.
Prevention of Caries
The increased tooth retention of older individuals makes primary prevention and early (less invasive) treatment increasingly important for those over the age of 50.15 Today's older adults have not benefited from a lifetime exposure to such preventive therapies as fluorides and dental sealants. The potential for disability and handicap can be effectively reduced, however, through low-invasive restorative approaches and fluorides. Much of what is known about preventing and controlling dental caries is based on children, although epidemiological data in young adults suggest that fluorides, which are proven to be efficacious in children, continue to work in adults.47 Thus, for high-risk individuals, including those undergoing cancer treatment (chemotherapy and ionizing radiation), additional fluoride treatments are indicated to prevent oral sequelae.
Loss of salivary flow and changes in salivary composition are risk factors for caries. In some cases, medications may need to be altered. In other cases, agents to maintain a moist oral environment are used for patients at risk. Altering this risk requires interaction between dentists and physicians regarding medications and systemic diseases.
Prevention of Gingivitis and Periodontitis
Dental plaque retention is a major problem in older adults and is often exacerbated by existing restorations, rough root surface topology, and an inability to brush sufficiently. Diminished manual dexterity—in addition to more severe functional limitations associated with, for example, stroke, arthritis, or Parkinson's disease—may lead to a decreased ability to use a toothbrush and interdental devices.29 For some, self-care may not be physically possible.32 In addition, the motivation to prevent diseases and learn new techniques may be weaker in older individuals than for younger adults.
The prevention of gingivitis and periodontitis is directed toward altering the risk factors for these oral diseases. The most widely accepted methods are personal and professional mechanical oral hygiene measures (toothbrushing and interdental cleaning). If appropriately performed, these practices should substantially minimize the loss of teeth from periodontal diseases.
Prevention of Oral Pain
Reduction in oral dysfunction related to oral pain requires a better understanding of orofacial pain, appropriate interventions, and
control of contributing diseases and conditions. In general, the selection of the mode of treatment for both acute and chronic pain will depend on the nature of the pain and various patient characteristics. Antidepressant medication has been useful for modulation of chronic pain. It should be noted, however, that dosages of antidepressants for chronic pain management are significantly lower than those needed for management of clinical depression. Premedication with nonsteroidal analgesics has been shown to be effective in modulating postoperative pain. A key challenge is the prevention and management of lesions in denture wearers and other related problems.
If the burdens of oral dysfunction in the older population are to be reduced, the barriers to self-care and professionally provided care must be removed. Of all the direct and indirect risk factors for oral dysfunction among older adults, the use of professionally provided services is the most affected by social, economic, environmental, and individual resources.14 Social and economic factors, including lower levels of education, rural residence, and inability to pay, have been linked to the underutilization of services. Moreover, increased risk for candidiasis, denture ulcers, root caries, coronal caries, gingivitis, and periodontal disease has been linked to inadequate dental care in institutional settings.8
Besides factors such as the ability to pay and accessibility to care, the barriers to improved oral health often include a number of indirect factors that are correlated with oral functional impairments. For example, cultural and environmental conditions may predispose populations to oral health difficulties. Whether a community's water supplies are fluoridated, whether language barriers exist for individuals who seek preventive care—factors such as these should be taken into account in establishing methods for reducing the risks of oral diseases.
Attitudes, beliefs, and behaviors that predispose individuals to oral health problems can be modified through education. For example, fear, concerns for personal appearance, the value an individual places on oral health and dental care, and ignorance of oral health and prevention and treatment techniques can be overcome by educational efforts. Such information is especially important for older individuals who may never have learned appropriate dentally related behaviors or whose knowledge of prevention may be outdated.
Misinformation and confusion often discourage older persons from changing behaviors or seeking preventive services. In addition,
the stereotypes of aging may undermine motives for maintaining oral health. These types of barriers can be eliminated in part by knowledgeable, caring providers whose attitudes, beliefs, and behavior are crucial to the oral health of a population. The dental health professional's knowledge of oral diseases, conditions, and preventive therapies, especially as related to older populations, substantially affects the prevention of oral health problems. Also of importance are the priority placed on oral health by physicians, nurses, and other non-dental health professionals and the information health care professionals can provide regarding financial assistance programs.
These general recommendations represent a broadly gauged approach to the complex oral health problems confronting older Americans, now and in the future. If they are undertaken with energy and resourcefulness, improved function, an enriched quality of life, and better overall health will result for these citizens.
The proportion of the population who receive their water through optimally fluoridated public water systems should be increased.
The proportion of the population, as appropriate, who receive the benefits of fluoride through other means should also be increased.
Mechanisms should be developed to encourage interaction among dentists, pharmacists, physicians, and other health care providers to enhance the oral health of older adults.
Studies should be conducted to examine the prevalence, incidence, cohort differences, and risk factors of oral dysfunction in older adults (e.g., tooth loss, oral cancer, oral mucosal conditions, oral sequelae of systemic diseases, chronic orofacial pain, trauma, salivary gland dysfunction, and aspects of caries and periodontal diseases).
The accuracy and feasibility of complete and abbreviated oral cancer screening procedures in primary care settings should be tested for both high-risk groups and the total adult population.
The pattern of developing oral functional disabilities and their underlying causation should be determined, and longitudinal studies of the natural history and microbiology of oral diseases should be conducted.
Investigations should continue to elucidate and characterize oral changes associated with "normal aging" and to assess their impact on oral function.
The relationship of systemic conditions, medications, and orofacial conditions in older adults should be explored.
Studies should be performed to investigate the lifelong effects of fluorides on dental caries in older adults.
The utilization of dental services by the elderly (both dentate and edentulous) should be assessed.
Methods/measures should be developed to identify older individuals at high risk for oral functional disabilities.
Acceptable definitions of quality of life outcome measures should be established, including a definition of functional dentition.
New methods of oral health care delivery for older adults should be developed, evaluated, and demonstrated. These innovations should include the delivery of services within the existing health care system or through alternate settings.
The use of preventive and early oral health diagnostic services should be encouraged through public- and private-sector incentives to expand and extend dental benefits to the retired population and through incentives for dental professionals to provide care to compromised older adults outside traditional dental care settings (e.g., long-term care facilities, mobile vans, portable equipment, institutions).
Within 30 days of entry into an institution, individuals should receive an oral examination and any required urgent care services. Annual oral examinations should be performed as needed.
Policies should be promoted to provide preventive services for currently underserved older adults.
Educational efforts promoting cessation of tobacco and alcohol use should be increased.
Self-assessment instruments should be developed and tested to assist individual older adults and auxiliary health care professionals to learn the signs and symptoms of oral diseases.
The effectiveness of existing educational materials should be assessed.
Material should be developed specifically for dentate older adults and for particularly needy subpopulations (e.g., the homebound, the institutionalized), including information on self-care and the availability of services.
Institutional education programs for health professionals should be enhanced to improve knowledge, attitudes, and behaviors regarding primary prevention, diagnosis, and treatment for oral functional disabilities of older adults.
This chapter is based, in part, on recent publications and meeting presentations and deliberations from workshops sponsored by the U.S. Public Health Service and the National Institutes of Health, addressing oral health promotion for adults and older Americans. These materials are not otherwise cited in the references and are thus listed below. Numbered references from the chapter follow.
Gift, H. C. Issues of aging and oral health promotion. Gerodontics 1988; 4:194-206.
National Institute of Dental Research. Challenges for the Eighties: National Institute of Dental Research Long-Range Plan. Washington, D.C., December 1983.
Oral Health Working Group, U.S. Surgeon General's Workshop on Health Promotion and Aging. Recommendations for oral health promotion activities with older adults. Gerodontics 1988; 4:207-208.
A Research Agenda for Health Promotion and Disease Prevention for Children and the Elderly. Health Services Research 1985; 19(6):Part 2.
A Research Agenda on Oral Health in the Elderly. Bethesda, Md.: National Institute on Aging, National Institute of Dental Research, and the Veterans Administration, 1986.
Corbin, S. B., Gift, H. C. and Singer, M. M. Draft National Oral Health Objectives for the Year 2000. Richmond, Va.: American Association of Public Health Dentistry, January 1990.
1. American Cancer Society. Cancer Facts and Figures, 1987. New York: American Cancer Society, 1987.
2. Antczak, A. A., and Branch, L. G. Perceived barriers to the use of dental services by the elderly. Gerodontics 1985; 1:194-198.
3. Banting, D. W. Dental caries in the elderly. Gerondontology 1984; 3(1):55-61.
4. Baum, B. J. Characteristics of participants in the oral physiology component of the Baltimore Longitudinal Study of Aging. Community Dentistry and Oral Epidemiology 1981; 9:128-134.
5. Baum, B. J. Research on aging and oral health: An assessment of current status and future needs. Special Care in Dentistry 1981; 1(4):156-165.
6. Baum, B. J., and Bodner, L. Aging and oral motor function: Evidence for altered performance among older persons. Journal of Dental Research 1983; 62(1):2-6.
7. Beck, J. D. The epidemiology of dental diseases in the elderly. Gerondontology 1984; 3(1):5-15.
8. Beck, J. D., and Hunt, R. J. Oral health status in the United States: Problems of special patients. Journal of Dental Education 1985; 49:407-425.
9. Beck, J. D., Kohout, F. J., Hunt, R. J., and Heckert, D. A. Root caries: Physical, medical and psychosocial correlates in an elderly population. Gerodontics 1986; 3:242-247.
10. Blott, W. J., McLaughlin, J. K., Winn, D. M., et al. Smoking and drinking in relation to oral and pharyngeal cancer. Cancer Research 1988; 48:3282-3287.
11. Bouquot, J. E. Common oral lesions found during a mass screening examination. Journal of the American Dental Association 1986; 112:50-57.
12. Corbin, S. B., Maas, W. R., Klienman, D. V., and Backinger, C. L. 1985 National Health Interview Survey findings on public knowledge and attitudes. Public Health Reports 1987; 102:53-60.
13. Davies, A. M. Epidemiology and the challenge of aging. In: J. A. Brody, and G. L. Maddox (eds.), Epidemilogy and Aging. New York: Springer Publishing Company, 1988, pp. 3-23.
14. Dolan, T. A., Corey, C. R., and Freeman, H. E. Older Americans' access to oral health care. Journal of Dental Education 1988; 52(11):637-642.
15. Douglass, C. W., and Gammon, M. D. Implications of oral disease trends for the treatment needs of older adults. Gerodontics 1985; 1(2):51-58.
16. Ettinger, R. L. Oral disease and its effect on the quality of life. Gerodontics 1987; 3:103-106.
17. Ettinger, R. L., and Miller-Eldridge, J. An evaluation of dental programs and delivery systems for elderly isolated populations. Gerodontics 1985; 1:91-97.
18. Evashwick, C., Rowe, G., Diehr, P., and Branch, L. Factors explaining the use of health care services by the elderly. Health Services Research 1984; 19(3):357-382.
19. Gambucci, J. R., Martens, L. V., Meskin, L. H., and Davidson, G. B. Dental care utilization patterns of older adults. Gerodontics 1986; 2:11-15.
20. Gift, H. C. Awareness and assessment of periodontal problems among dentists and the public. International Dental Journal 1988; 38:147-153.
21. Gift, H. C. Utilization of professional dental services. In: L. K. Cohen and P. S. Bryant (eds.), Social Sciences and Dentistry, vol. 2 . London: Quintessence Publishing Company, 1984, pp. 202-266.
22. Greenlick, M. R., Sarvey, R., Lamb, S., et al. Prepaid dental care for the elderly in an HMO Medicare demonstration. Gerodontics 1986; 2:131-134.
23. Hand, J. S., and Hunt, R. J. The need for restoration and extractions in a non-institutionalized elderly population . Gerodontics 1986; 2:72-76.
24. Hand, J. S., Hunt, R. J., and Beck, J. D. Incidence of coronal and root caries in an older adult population. Journal of Public Health Dentistry 1988; 48(1):14-19.
25. Holtzman, J. M., and Berkey, D. B. Predicting utilization of dental services by the aged. Paper presented at the 40th Annual Scientific Meeting of the Gerontological Society of America, Washington, D.C., 1987.
26. Hughes, J. T., Rozier, R. G., and Ramsey, D. L. Natural History of Dental Diseases in North Carolina, 1976-1977. Durham, N.C.: Carolina Academic Press, 1988, pp. 250-254.
27. Hunt, R. J. Periodontal treatment needs in an elderly population in Iowa. Gerondontics 1986; 2:24-27.
28. Hunt, R. J., Srisilapanan, P., and Beck, J. D. Denture-related problems and prosthodontic treatment needs in the elderly. Gerodontics 1985; 1:226-230.
29. Irving, P. W. Diseases in the elderly with implications for oral status and dental therapy. In: P. Holm-Pedersen and H. Loe (eds.), Geriatric Dentistry, A Textbook of Oral Gerontology. Copenhagen: Munksgaard, 1986, pp. 179-186.
30. Kasper, J. A., Rossiter, L. F., and Wilson, R. A summary of expenditures and sources of payment for personal health services from the National Medical Care Expenditure Survey. NCHSR Data Preview No. 24. Washington, D.C.: U.S. Department of Health and Human Services, 1987.
31. Kiyak, H. A. An explanatory model of older persons' use of dental services: Implications for health policy. Medical Care 1987; 25(10):936-952.
32. Kiyak, H. A. Oral health promotion for the elderly. In: J. D. Matarazzo, S. M. Weiss, J. A. Hard, et al. (eds.), Behavioral Health: A Handbook of Health Enhancement and Disease Prevention. New York: J. Wiley, 1984, pp. 967-975.
33. Kiyak, H. A., and Mulligan, K. Studies of the relationship between oral health and psychological well-being. Gerodontics 1987; 3:109-112.
34. Levy, S. M., Baker, K. A., Semla, T. P., and Kohout, F. J. Use of medications with dental significance by a non-institutionalized elderly population. Gerodontics 1988; 43:119-125.
35. Loe, H., and Kleinman, D. (eds.) Dental Plaque Control Measures and Oral Hygiene Practices. Oxford: IRL Press Limited, 1986.
36. Mandel, I. D. Oral defenses and disease: Salivary gland function. Gerondontology 1984; 3(1):47-54.
36a. Mashberg, A., and Samit, A. M. Early detection, diagnosis, and management of oral and oropharyngeal cancer. CA: A Cancer Journal for Physicians 1989; 39(2):67-88.
37. Meskin, L. H., Brown, L. J., Brunelle, J. A., and Warren, G. B. Patterns of tooth loss and accumulated prosthetic treatment potential in U.S. employed adults and seniors, 1985-86. Gerodontics 1988; 4:126-135.
38. National Center for Health Statistics. Health promotion and disease prevention, United States, 1985. Vital and Health Statistics, Series 10, No. 163, 1988.
39. National Center for Health Statistics. Use of dental services and dental health, U.S., 1986. Vital and Health Statistics, Series 10, No. 165, 1988.
40. National Income and Product Account. Washington, D.C.: Bureau of Economic Analysis, U.S. Department of Commerce, 1986.
41. National Institute on Aging. Personnel for Health Needs of the Elderly through the Year 2000. Washington, D.C.: U.S. Public Health Service, September 1987.
42. National Study of Dental Health Outcomes Related to Prepayment: 1981. Rockville, Md.: Health Resources and Services Administration, 1987.
43. Oral Health of United States Adults: National Findings. NIH Publ. No. 87-2868. Washington, D.C.: National Institute of Dental Research, U.S. Department of Health and Human Services, 1987.
44. Page, R. C. Periodontal diseases in the elderly: A critical evaluation of current information. Gerontology 1984; 3(1):63-70.
45. Reisine, S. Defining social consequences in dentistry Paper presented at the 60th General Session of the International Association for Dental Research, New Orleans, La., March 1982. (Abstracts in the Journal of Dental Research, March 1982.)
46. Rosenberg, D., Kaplan, S., Senie, R., and Badner, V. Relationships among dental functional status, clinical dental measures, and generic health measures. Journal of Dental Education 1988; 52(11):653-657.
47. Stamm, J. W., and Banting, D. W. Comparison of root caries prevalence in adults with life-long residence in fluoridated and nonfluoridated communities. Journal of Dental Research 1980; 59:405.
48. U.S. Preventive Services Task Force. Guide to Clinical Preventive Services. Baltimore, Md.: Williams and Wilkins, 1989.
49. Weintraub, J. A., and Burt, B. A. Oral health status in the US: Tooth loss and edentulism. Journal of Dental Education 1985; 49(6):368-376.
50. Wilson, A. A., and Branch, L. G. Factors affecting dental utilization of elders aged 75 years or older. Journal of Dental Education 1986; 50(11):673-677.
51. Wolinsky, F. D., and Arnold, C. L. A birth cohort analysis of dental contact among elderly Americans. American Journal of Public Health 1989; 79(1):47-51.