Original article

Epidemiology of oral health conditions in older people

William Murray Thomson
Sir John Walsh Research Institute, School of Dentistry, The University of Otago, Dunedin, New Zealand

doi: 10.1111/ger.12085
Epidemiology of oral health conditions in older people
The main conditions of interest when considering the epidemiology of oral diseases among older people
are tooth loss, dental caries, periodontitis, dry mouth and oral pre-cancer/cancer, along with oralhealth-related quality of life (OHRQoL). This article presents an overview of what is known about the
epidemiology of each of the main conditions of interest among older populations.
Keywords: older people, dental caries, tooth loss, periodontal diseases, oral mucosa, xerostomia, dry
mouth, epidemiology.
Accepted 17 September 2013
The oral health of older people has warranted
considerable research attention in the last two to
three decades. Much of that research has been
clinical in nature and conducted on clinical convenience samples, but a fair number of epidemiological studies have also been conducted and
reported. Epidemiology is the study of the occurrence of health and ill health in populations; as
such, it requires that population-based samples be
used, so that inferences about oral health in the
source population can be made from the measurements conducted on those samples. That is,
the data should be from representative samples.
Moreover, a useful distinction can be made
between descriptive epidemiology and analytical
epidemiology: the former seeks to describe the
occurrence of a condition or health state using
surveys, while the latter seeks to identify putative
risk factors and clarify the temporal sequence
between exposure and outcome, using cohort or
casecontrol studies. The purpose of this article is
to provide an overview of what is currently
known of the epidemiology of oral health and disease in older people. A key underlying principle
will be that only data from epidemiological studies
will be used.
Interest in the older population has increased
immensely in recent years, largely in response to
the imperative faced by industrialised countries,
where a phenomenon termed the demographic
transition has been underway3. Concurrent with
increasing life expectancy has been a fall in the
birth rate; in other words, people are living

longer, and women are having fewer babies and

are tending to have them later. As a result, the
affected countries are undergoing shifts in their
population structure such that older people comprise an increasing proportion of the population.
Japan has led the way in this phenomenon: people aged 65 or more currently comprise 23% of
the Japanese population and are expected to
make up 38% by 205019. This phenomenon may
not be as marked in other developed countries,
but the same trends are evident. In China, the
equivalent estimates are 8% and 23%; in Europe,
they are 16% and 27%; in North America, they
are 13% and 22%. New Zealand is undergoing a
similar process, whereby the 14% of the population currently aged 65 or more is expected to rise
to 25% by 2050; within that group, people aged
80 or more currently comprise about 25%, but
that proportion will be 40% by 2050. Less developed countries have dramatically different age
structures. A recent analysis by Ezeh et al.19 classified countries according to their current population growth rates (Table 1), with rapid growth,
moderate growth, low/no growth and decline profiles identified. The demographic transition may
be occurring at a faster rate in the moderate
growth countries than it did historically in those
which now have much lower growth rates. As
with other aspects of health, the oral health challenges will not be the same in the four categories
of country in Table 1. For example, a recent commentary highlighted the complexity of the oral
health challenges faced by older people in

2014 John Wiley & Sons A/S and The Gerodontology Society. Published by John Wiley & Sons Ltd,
Gerodontology 2014; 31 (Suppl. 1): 916

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W. Murray Thomson

Table 1 Growth rate profiles (after Ezeh et al.19).

Growth rate type

Characteristics

Examples

Rapid growth
(>2% p.a.)

High fertility, moderate-to-low

mortality. Size will double by 2050

Moderate growth
(12% p.a.)
Low/no growth
(<1% p.a.)
Decline (<0% p.a.)

Lower death rates, declining fertility

Much of sub-Saharan Africa,

parts of South Asia, the Arabian
peninsula and some small
countries in Latin America
India, Indonesia, north Africa,
western Latin America
USA, Canada, China, Brazil,
much of Europe
Germany, Japan, Russia,
much of eastern Europe

Low fertility, population ageing

Fertility below the replacement
level

Africa37, with demographic, geographical, sociocultural and political influences all operating
alongside the usual dental and medical considerations. Such influences operate in any system, of
course, but the situation in Africa appears to be
particularly complex.
The main conditions of interest when considering oral diseases among older people are tooth
loss, dental caries, periodontitis, dry mouth and
oral pre-cancer/cancer45. Complementing this disease-related focus is the notion of oral-healthrelated quality of life (OHRQoL), on which
considerable research effort has been focused in
the last two decades, to the point where we are
now able to identify the conditions which have
the greatest effects on older peoples day-to-day
lives and comfort. Indeed, it is now standard procedure in dental epidemiological surveys to collect
information on self-reported oral health (whether
with a single global rating or with a validated
OHRQoL scale) alongside the usual clinical examination data. The issue of self-reported oral health
is discussed further below, but an overview of
what is known about the epidemiology of each of
the main conditions of interest among older populations is presented first.
Tooth loss
Even though most tooth loss occurs as a consequence of dental caries and periodontitis, it is useful to consider the formers occurrence before
thinking about the latter two conditions. When
considering tooth loss, a distinction needs to be
made between edentulism (the state of having
lost all of the natural teeth) and the more common incremental loss of teeth which tends to
occur throughout adult life. The transition
to edentulism requires an explicit decision to
undergo complete removal of the dentition (or

what remains of it) in a single operation. That

process usually involves the removal of intact,
functioning teeth; the decision to undergo it is as
much socially driven as it is clinical. The reasons
for edentulism are both disease-related and societal66, and this is reflected in well-documented
international variations in the states occurrence.
In industrialised countries, the prevalence of edentulism has fallen markedly49,58. Edentulism is
most commonly regarded by dental public health
observers as an undesirable endpoint, embodying
the failure of both self-care and the dental care
system to ensure the retention of a functional
dentition for the person involved. Edentulous people have been shown to have poorer diets and
associated nutrition than those with natural
teeth39,41. Not only are there nutritional disadvantages to being edentulous, the day-to-day lives of
edentulous people may be affected especially in
relation to the domains of chewing and eating
by having no teeth or wearing poor dentures51,52.
Thus, edentulism has both nutritional and social
consequences; it is not a particularly benign state.
Be that as it may, it is not all negative. For example, undergoing a full clearance may be a considerable relief to the person involved, with the
removal of all remaining natural teeth heralding
the end of what may have been decades of misery
and eating problems. Another advantage of being
edentulous is that there is no longer anything
which is susceptible to dental caries or periodontal
attachment loss, and institutionalised care later in
the life-course is likely to have fewer orodental
complications.
Nowadays, incremental tooth loss is altogether
more common than edentulism, among adults of
all ages. For example, data from two national surveys conducted 33 years apart in New Zealand
show that, despite a considerable fall in the prevalence of edentulism66, that of incremental tooth

2014 John Wiley & Sons A/S and The Gerodontology Society. Published by John Wiley & Sons Ltd,
Gerodontology 2014; 31 (Suppl. 1): 916

Epidemiology of oral health conditions

loss did not change among older adults (Fig. 1).

A number of reports have been published on the
occurrence of incremental tooth loss in cohort
studies of older adults14,16,22,34,44,54,68, and their
findings confirm that it is an ongoing problem in
those aged 65 or older. Incremental tooth loss is
less predictable and therefore more of a prosthodontic challenge, given that its sequelae can
include the drifting or over-eruption of the teeth
which remain. Moreover, given evidence from
younger populations that one of the major predictors of poor OHRQoL is incremental tooth loss32,
it is likely that older adults in that situation are
also likely to experience effects on their day-today lives.
Dental caries
It is not that long since any discussion of dental
caries among older people was largely confined to
the issues of root surface caries and the maintenance of restorative work which had been placed
decades previously. There was a perception that
dental caries was, for the most part, active only in
younger people. However, a number of reports
have appeared in the last decade or two from prospective cohort studies of population-based samples of community-dwelling older people22,28,29,60,
and these have filled a large gap in knowledge of
the natural history of dental caries in that age
group. Their findings were surprisingly consistent,
and showed that dental caries is active among
older people, with a mean increment of about 1
surface per year24,61, which is similar to that
observed through life until the early thirties6.
Moreover, while both coronal and root surface
caries contributed to the observed increments
among older people, there was a consistent pat-

Figure 1 Prevalence of one or more teeth missing due

to caries among New Zealand adults in 1976 and 2009.

11

tern, whereby coronal caries made the greater

contribution to the overall increment. Longitudinal research conducted in South Australia demonstrated that the annual dental caries increment
among older people residing in nursing homes is
more than double that observed among their
community-dwelling counterparts; among those
with dementia, it is twice as high again8.
Periodontitis
There are challenges in describing the occurrence
of periodontitis in older people and in determining whether there have been changes over time.
The indices and methods which are used have
changed in recent decades27, evolving from the
visual-only approach of Russells Periodontal
Index48, through the snapshot method of the
Community Periodontal Index of Treatment
Needs (CPITN)1, to the current attachment loss
approach. While this has been a necessary evolution, it complicates epidemiological comparisons,
not least because of the persisting heterogeneity
in methods, with some studies continuing to use
outdated indices. There are also recent indications
that the partial recording protocols (PRPs) used to
collect the available data may have resulted in
underestimates of the true prevalence and extent
of the condition43. Nonetheless, it is possible to
assemble an overview of periodontal status in
older people from the limited epidemiological data
which are available. Those data tend to be from
developed countries.
A review by Locker et al.35 in Periodontology
2000 summarised knowledge of the occurrence of
periodontitis in older populations at that time.
They found that most older people have some
experience of the disease, with moderate levels of
attachment loss. A substantial minority have
advanced attachment loss, but that affects relatively few sites. The scarce longitudinal data of
the time indicated that a substantial minority
have ongoing attachment loss. It was pointed out
that the marked incremental tooth loss which is
usually seen among older adults means that the
remaining dentition comprises the healthy survivors, meaning that lifetime periodontitis experience has likely been underestimated. The authors
considered the issue of whether ageing per se is a
risk factor for attachment loss and concluded that
the available evidence supported that notion.
Fifteen years on, have we learned anything
new? There have been a number of reports of
periodontitis prevalence (most of which have
been from countries which have had previous

2014 John Wiley & Sons A/S and The Gerodontology Society. Published by John Wiley & Sons Ltd,
Gerodontology 2014; 31 (Suppl. 1): 916

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W. Murray Thomson

prevalence studies17), and almost all are from

countries in the Low/No or Decline growth categories of the Ezeh et al. typology. Only a very
small number have come from those in the Moderate or Rapid growth categories, and they have
not been that informative. Ronderos et al.47
reported on periodontal disease among an isolated
indigenous population in Southwestern Colombia,
but that was a convenience sample, and there
were only 24 people in the 50+ age group; one of
those apparently had severe attachment loss.
Dowsett et al.15 reported on the periodontal status
of a Guatemalan population, but there were only
17 people aged 55 or older, and it was not possible to determine the prevalence of periodontitis
from the report. Torrungruang et al.67 investigated
the condition in Thai adults aged between 50 and
73, assigning them to three periodontal severity
groups based on their mean CAL. One in six had
what was described as severe periodontitis
(defined as a mean CAL of 4+mm) and over-represented among those were males, smokers and
those with a low education level. Borges-Yanez
et al.4 reported that half of a random sample of
Mexicans aged 60 and older had moderate or
severe periodontitis (respectively defined as 2+
sites with 4+mm attachment loss and 1+ sites
with 6+mm attachment loss); they did not report
the latter separately, unfortunately. There were
marked differences by sex, socio-economic status,
rurality and smoking status. Gamonal et al.20
reported periodontal findings from the first
national survey of Chile, where it was found that
two-thirds of those aged 6574 years had attachment loss of 6 mm or more at at least one site.
These reports from Moderate or Rapid growth
countries encapsulate the challenges in comparing
findings from studies with different data collection
and reporting approaches.
Perhaps the most notable development in our
knowledge of periodontitis among older people
has been a small but important increase in the
number of reports from longitudinal studies of
population samples18,21,26,46,62. These have suggested higher progression rates among older people in developing countries than in developed
ones, but there remains a paucity of reports from
countries with Rapid or Moderate growth rate
profiles, and this cannot yet be confirmed. The
findings of the existing longitudinal studies suggest that: there is a great deal of progression and
remission; that a considerable proportion of incident attachment loss in older people manifests as
increases in gingival recession rather than pocket
depth; most incident disease occurs at sites which

have not previously experienced it (although person-level previous disease experience is a strong
predictor); and smoking does not appear to be as
strong a predictor as seen in younger adults. The
latter may be due to healthy survivor effects operating at both person and tooth levels.
It is worthwhile at this point to make some
methodological comments. It was difficult to
make comparisons among the periodontal studies
(whether cross-sectional or longitudinal) because
of a lack of uniformity in methods, sampling and
(not least) reporting. In working to change this,
the onus is not just on scientists but also on
reviewers and editors. Moreover, the World
Health Organization database (http://www.dent.
niigata-u.ac.jp/prevent/perio/contents.html) did not
have much in the way of recent or national-level
data: of the estimates from the 38 countries listed
on it at the time of writing, only 9 were nationallevel and all were based on the uninformative
and now-outdated CPI recording system. The proportion of 65- to 74-year-olds with at least one
CPI score of 4 ranged from 4% in New Zealand to
40% in Germany, and there was considerable variation in between those two estimates.
Oral pre-cancer/cancer
The terms oral precancer and oral cancer cover
a number of lesions of the oral mucosa, but the
former term generally refers to leukoplakia, lichen
planus and erythroplakia, conditions with recognised potential (especially the latter) for malignant transformation. The term oral cancer
generally refers to oral squamous cell carcinoma23. Recent prevalence estimates from representative samples are scarce, but it has been
observed that most cases of oral cancer occur
among older people and that they are more frequent in less developed countries than developed
ones45.
Recent New Zealand experience illustrates the
difficulties of obtaining valid and reliable estimates of the occurrence of oral cancer among
older populations. In what is believed to be the
first-ever national survey of oral health in older
people living in nursing homes or with Statefunded domestic support in their own homes,
only 16 (0.8%) of the 1885 people examined
were referred for the investigation of suspicious
lesions (and, so far, five of those have been
reported not to be cancer). Clearly, any detailed
investigation of the occurrence of such lesions
would need to use a very large representative
sample.

2014 John Wiley & Sons A/S and The Gerodontology Society. Published by John Wiley & Sons Ltd,
Gerodontology 2014; 31 (Suppl. 1): 916

Epidemiology of oral health conditions

Oral cancer is a uncommon disease which can

have catastrophic personal consequences for sufferers; its death-registration ratio has been
reported to be comparable to those of breast cancer and cervical cancer, and greater than that of
melanoma31. Tobacco is the most well-known risk
factor and is known to exert a synergistic effect
with heavy alcohol use5. Recent work has also
implicated human papillomavirus (HPV) in the
occurrence of oropharyngeal cancer, particularly
among younger adults9,11.
Dry mouth
Chronic dry mouth occurs in a substantial proportion of older people, affecting sufferers oralhealth-related quality of life through its effects on
aspects such as speaking, the enjoyment and
ingestion of food, and the wearing of dental prostheses7,36,64. The term dry mouth encapsulates
two aspects which may occur together or separately, and it is important to distinguish between
these and to be clear about which is being
reported on in any given study. The term xerostomia usually refers to the subjective feeling of dry
mouth, whereas low salivary flow is referred to as
salivary gland hypofunction (SGH)25,30. Each
aspect can be a threat to the dentition: those with
low salivary flow rates may be at risk of dental
caries because of their compromised salivary
buffering and remineralisation; and those with
xerostomia may be taking measures to relieve
their dry mouth symptoms (such as frequent sucking on sweets) which themselves promote dental
caries.
Rates of dry mouth are generally higher among
older people. Indeed, most epidemiological studies
of the condition have been undertaken using
samples of older adults, with only two reports
from younger adults40,65. Although comparing
epidemiological estimates from studies of older
populations is complicated by inconsistencies in
measurement and the use of a range of case definitions and approaches, it is possible to conclude
that about one in five older people suffers from
dry mouth42,63.
Turning to the risk factors for dry mouth, medication use is the most important one at the epidemiological level, with higher prevalence rates
observed in those taking particular classes of medication. Prominent among those are antidepressants,
respiratory
agents,
opiate-containing
analgesics, or some cardiac or antihypertensive
drugs56,59. The concept of the overall anticholinergic burden10 is relevant here: other factors being

13

equal, the greater the exposure (in terms of number and dosage) to drugs with an anticholinergic
effect, the greater the likelihood and severity of
side effects such as dry mouth. Given the current
state of knowledge of the putative association
between medications, dry mouth and dental caries, it is not possible to determine whether older
people taking particular medications are at greater
risk of caries, with the only evidence from an
analytical epidemiological study favouring no
association60. Nevertheless, dry mouth should be
considered to be an important oral condition
among older populations because of its effects on
sufferers quality of life.
Oral-health-related quality of life (OHRQoL)
The preceding discussion has focused upon oral
conditions rather than oral health per se. Let us
not forget that the traditional dental indices (such
as DMFT and CPITN) are actually disease measures, rather than measures of oral health per se.
Growing awareness since the mid-1970s of the
traditional measures deficiencies50 led to calls for
the development of what were initially termed
sociodental indicators12. It has become accepted
that health is a subjective state, and oral health is
no exception. Locker introduced the concept of
oral-health-related quality of life (OHRQoL) and
adapted the World Health Organizations WHO
model of the International Classification of
Impairments, Disabilities and Handicaps to oral
health33. The associated development, testing and
field use of OHRQoL measures2,13,38,5153 have led
to a far greater understanding of the impact of
poor oral health on older adults.
The validation and use of adult OHRQoL measures in younger age groups (and, indeed, in
those as young as 15) have led to a recent reconsideration of such data from older people. Slade
and Sanders55 used Australian national oral
health survey data to highlight the apparent paradox of lower OHIP-14 scores among older adults.
Although those findings were from a cross-sectional study meaning that no definitive inferences can be made about changes in self-perceived
oral health with ageing the data raise some interesting issues, especially because the phenomenon
is also apparent in other industrialised countries.
The authors stressed that we should not assume
that older people are necessarily disabled by their
accumulated burden of clinical oral disorders
(such as tooth loss, dental caries, periodontal
attachment loss and dry mouth); rather, their
age-associated stoicism, adaptability, capacity for

2014 John Wiley & Sons A/S and The Gerodontology Society. Published by John Wiley & Sons Ltd,
Gerodontology 2014; 31 (Suppl. 1): 916

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W. Murray Thomson

coping and the associated response shift57 mean

that most manage reasonably well from day to
day.
Notwithstanding those considerations, it is possible to determine from the epidemiological literature which oral conditions have the greatest
impact upon older people. Irrespective of the selfreport instrument or approach, OHRQoL tends to
be poorer among those who wear dentures, have
higher numbers of missing teeth or decayed teeth,
or have dry mouth. An association with periodontitis has yet to be demonstrated. Difficulty in eating is a common finding.

Conclusions
This overview of oral health and disease in older
populations has used data from epidemiological
studies to consider tooth loss, dental caries, periodontitis, dry mouth and oral pre-cancer/cancer,
along with OHRQoL among older people.
Although complete tooth loss is declining, incremental tooth loss continues and is an important
determinant of poor OHRQoL. Dental caries continues to be the most prevalent condition and is
known to be active in the older age groups. Periodontitis is apparent to some degree in most older
people, with a substantial minority having more
advanced disease. Oral cancer is not common, but
it can be catastrophic for sufferers. It occurs more
frequently in less developed countries. Dry mouth

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Acknowledgements
The contributions of my colleagues Dr Philip
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Conflicts of interest
None declared.

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Correspondence to:
W. Murray Thomson,
Sir John Walsh Research
Institute, School of Dentistry,
The University of Otago,
Dunedin, New Zealand.
Tel.: +64 34797116
Fax: +64 34797113
E-mail: murray.thomson@otago.
ac.nz

2014 John Wiley & Sons A/S and The Gerodontology Society. Published by John Wiley & Sons Ltd,
Gerodontology 2014; 31 (Suppl. 1): 916