Article Archive
May/June 2023

The Hidden Risks of Oral Infections
By Michele Deppe
Today’s Geriatric Medicine
Vol. 16 No. 3 P. 18

Improving oral health could reduce the risk of serious diseases and chronic conditions.

One of the risk factors for heart disease and other medical conditions is beyond our control: living to the age of 50 and older.1 Thankfully, healthy lifestyle choices and good medical care can minimize many other risk factors. One of the most important is maintaining good oral hygiene, a challenge for many older adults. To minimize the risks, health care providers should be alert to oral health issues and educate their patients about maintaining oral hygiene.

Risk Assessment
What is good oral hygiene? Experts agree that a baseline is brushing twice daily for about two minutes each time with a soft-bristled toothbrush, using fluoride toothpaste. In addition, flossing daily helps remove plaque, and swishing with mouthwash helps remove particles left behind. Seeing a dentist and hygienist for cleaning and exams every six months is essential. But that isn’t always possible for all individuals, especially those in long term care. “It’s hard for nursing homes to find dental providers who are willing to come in and see patients in that setting,” says Patrick P. Coll, MD, a lead researcher, the medical director for senior health, and the associate director for clinical geriatrics at the University of Connecticut Center on Aging. “Sometimes the difficulty is related to payment issues. What’s required is adjustments to the system to facilitate these vulnerable adults,” Coll says. Certified nursing assistants and others help greatly with daily oral hygiene, but a professional assessment and treatment from a dentist and hygienist are imperative. “In underserved and remote areas, technology may help,” Coll says. “There is some staff in long term care facilities that use little cameras, helping a dentist or dental hygienist to conduct a fairly good oral examination virtually.”

Common Dental Vulnerabilities in Older Adults
The CDC reports that nearly all adults aged 65 and older (96%) have had untreated tooth decay (cavities), and two in three older adults (68%) have gum disease.2

“Dry mouth, or xerostomia, is a big issue that impacts oral health in older adults,” Coll says. “Older adults, in general, are at risk for decreased saliva production, and some medications worsen the problem,” he says. He stresses that providers should be on the lookout for poor oral hygiene and symptoms of dry mouth, adding that dry mouth can cause dentures to be ill-fitting and make chewing, speaking, or swallowing uncomfortable.

According to a National Institute of Dental and Cranial Research paper, dry mouth contributes to decay and infection. 3 Saliva helps prevent cavities and other infections by cleansing the mouth with an antimicrobial effect. However, the aging process leads to degeneration of the salivary glands, causing less saliva to be produced. Various medications used by older people—including diuretics and antihypertension and antiparkinsonian drugs—can cause xerostomia, and the more prescriptions a person takes, the more dry mouth may increase. In addition, xerostomia can be accompanied by problems with mouth ulcers and Candida infection (thrush). It also can be a side effect of cancer treatment, diseases such as HIV/AIDS and diabetes, and nerve damage in the head or neck. Suggested strategies for reducing dry mouth, according to the report, include avoiding alcohol, caffeine, carbonated drinks, and spicy foods. Sugarless candy or chewing gum sometimes helps, and a health care professional may suggest using artificial saliva to help keep tissues moist.

Another contributor to poor oral health in older adults is their inability to properly manage their daily hygiene tasks and nourish themselves. “Manual dexterity goes down as you age, so older adults may not be able to take care of their teeth,” says Aadarsh Gopalakrishna, DDS, MS, an associate professor, the chair of general dentistry, and a research collaborator with Coll at the University of Connecticut. People with limited dexterity may be able to use an electric toothbrush and toothbrushes with larger handles, elastic bands, or a utensil holder to aid with gripping the brush.

Nearly one in five people in the United States older than 65 have lost all of their teeth, says the CDC, and complete tooth loss is twice as prevalent in people older than 75.

“Loss of teeth and having dentures affects a patient’s diet and nutrition status,” Gopalakrishna says, adding that chewing efficiency with dentures is very low, and as a result older patients with dentures or who have lost many teeth cannot eat certain foods. “They may rely on heavily processed foods that could lack essential nutrition for the body,” he says. “They may also opt for softer foods and miss out on foods with high fiber content, like vegetables and fruits, or meats with essential protein.”

Treating Oral Infections
Viral and fungal infections are common in older adults, as are infections of the bone or salivary glands. Abscessed teeth can also contribute to oral infections.

“Chronic oral infections must be addressed by dental care providers in a timely manner, which can prevent further complications and the acute onset of preexisting chronic oral infections,” Gopalakrishna says. Treatment options may include a course of antibiotics, surgical drainage, tooth extraction, or a root canal.

Correlations to Heart Disease and Other Diseases
A study published in the Journal of the American Geriatrics Society, led by Coll and coauthored by Gopalakrishna and others, emphasizes how oral infections can spread into surrounding tissues far from the mouth and that infection and bacteria can be released into the bloodstream.4 The study echoes other data confirming that oral infection is a recognized risk factor for heart disease.

“There are data in the medical literature showing an association between poor oral hygiene and certain medical conditions, including heart disease and diabetes,” Coll says. “It’s not clear why poor oral health might lead to issues with heart disease and diabetes, but it’s thought that it might be due to chronic inflammation.”

Periodontitis is a severe gum infection that damages soft tissues and can destroy the bone that supports teeth. “With coronary artery disease, there is a correlation between periodontitis and heart disease due to inflammatory pathways,” Gopalakrishna says. “When periodontitis, a chronic inflammatory disease in nature, contributes to inflammation in the body, the body can initiate an immune response to the bacteremia.”

And the heart also can influence oral health. “Hypertension can cause gingival bleeding, hyposalivation, and xerostomia, due to side effects of medications used to treat hypertension,” Gopalakrishna says. “These side effects can lead to an increased risk for dental caries.”

Uncontrolled diabetes is also linked to poor oral health, Gopalakrishna says. Poor glycemic control can increase the sugar level in saliva, increasing the susceptibility to oral infections, including more severe periodontitis. “Diabetes can cause diminished salivary flow, increased risk of caries, and oral candidiasis,” Gopalakrishna says. “It can also cause burning mouth syndrome and taste disturbances,” he adds.

Coll says there’s a connection between poor oral health and other medical issues related to artificial joints. “Many people have artificial hips and knees, and clearly when those joints are first put in, there’s a great deal of effort to ensure they don’t become infected in the perioperative period. There are also concerns about potential infection of these joints, even weeks, months, and potentially years after surgery, related to oral bacteria.” This is why, Coll explains, patients have received antibiotics before specific dental procedures if they’ve had a joint replacement. Fairly recently, Coll adds, this has become a somewhat controversial area regarding how long the antibiotic protocol should continue after the joint replacement.5 “But what is clear is if you have poor oral hygiene, even just brushing the teeth can cause bacteria to be released into the bloodstream, and sometimes those bacteria can end up in these joints and cause infections,” Coll says. “That’s an uncommon situation, but it’s such a serious problem, and it does occur. Optimizing oral hygiene is one way to reduce that risk.”

Alzheimer’s disease and dementia affect oral health. According to a 2021 study from Helsinki, Finland, findings pertaining to more than 200 older adults living in a long term care facility showed poor oral health according to “ODB scores” (the oral disease burden examination), indicating 35% had a high score due to an accumulation of oral bacteria, particularly in the residents with varying stages of dementia (which made up 68% of the participants).6 People with Alzheimer’s and other dementia may benefit from 5S methods—5 steps originally created for organizing efficient workplaces. These methods speak to how the patients’ spaces are organized. For example, unnecessary items are removed, and the oral care products are placed in the order they’ll be used. This simple intervention can help a person with dementia continue to practice oral hygiene.7

There’s a correlation between oral bacteria and aspiration pneumonia in older adults. One study found that one in 10 deaths from pneumonia in long term care facilities can be prevented by better oral care, including daily brushing, cleaning dentures, and increased professional care.8

People with rheumatoid arthritis are among those who may suffer from dry mouth, and these changes in saliva increase the risk of dental caries and periodontal disease, according to a 2020 meta-analysis.9 According to the analysis, rheumatoid arthritis and periodontitis are similar because they are chronic inflammatory diseases that affect connective tissue. Possibly because of this shared inflammatory pathway, the existence of periodontal disease increased the risk that one would have rheumatoid arthritis by 69%. A study from 2017 has shown that when adults receive nonsurgical periodontal treatment, they can experience an 18% reduction in their arthritis disease activity, as evidenced by less tender and swollen joints.10

Periodontitis is also associated with Parkinson’s disease. In a Taiwanese study, those with periodontitis were shown to have a 43% greater risk of developing Parkinson’s disease.11 Anti-Parkinson’s medications often cause dry mouth. The involuntary movements caused by the disease can cause jaw pain, teeth wear, and swallowing problems. Dental visits can be hindered by the person’s inability to cooperate with care because of confusion, sitting in the dental chair, and tremors.12

The third most common illness of disability worldwide is depression, and the CDC indicates that older adults often have undiagnosed and untreated depression. This is complicated by many older individuals’ belief that depression is a “natural” reaction to their illnesses, loneliness, and other challenging life changes.13 A review published in Clinical Oral Investigation revealed that older adults with depression had an increased risk for dental caries, tooth loss, and edentulism (lack of natural teeth).14 To complicate matters further, edentulism and periodontal disease can increase the risk of depression by 28%. Furthermore, antidepressant medications increase xerostomia. The review also found that some older people with depression turn to smoking and a cariogenic diet (one featuring sugary foods that promote decay).

Edentulism can also be a risk for dementia; one review concluded that older adults with several missing teeth were 55% more at risk of having dementia.15 Likewise, older people who retained their teeth had a 50% drop in their risk of developing dementia.16

Tooth wear increases throughout life; at age 20, wear is about 3%, and by age 70, it is about 17%.17 Although wear (and resulting smaller tooth size), chipping, fractures, and darker color are manifestations of aging, dental caries represent disease.

Also contributing to poor oral health is that the lining of the mouth becomes thinner with age. Because the thinner lining takes up toxic substances more readily and is less resistant to disease, older adults can be predisposed to precancerous and cancerous lesions in the mouth, on the lips, and on the pharynx.18

Oral cancers are primarily diagnosed in older adults and, according to the CDC, at the median age of 62. Although smoking is a risk for developing such cancers, older people who smoke are less likely to visit the dentist than are nonsmokers. Further, many older Americans don’t have dental insurance after retiring, and Medicare doesn’t cover routine dental care. Treatment for oral cancer includes surgery, chemotherapy, and radiation. Preventive measures include good hygiene and professional care of infections.

Another issue is oral frailty—deterioration of oral health due to frailty, indicators of which include factors related to disorders of chewing, swallowing, and saliva; oral pain; and deterioration of oral health status and oral motor skills.19 A nutritious diet helps reduce risk of frailty syndrome in older adults.

Oral problems and their relation to disease can be complicated issues to treat. As University of Utah professor Leslie R. Halpern, MPH, DDS, wrote in her published review of geriatric treatment strategies, “Oral diseases are not a discrete systematic illness but a combination of many with common causes.” As such, Halpern wrote, treating oral diseases will require a comprehensive approach.20

However, some oral care for older adults is simple. There’s a strong connection between fluoride and dental health, Coll says. Prescription-strength toothpaste containing a higher fluoride dose can be beneficial, particularly for people at high risk for dental caries. “The problem with them is they’re quite expensive,” Coll says. “I would like to see some mechanism where those types of treatments would be better reimbursed because I feel that many older adults in skilled nursing facilities could benefit.”

Oral health “is important to overall well-being and quality of life,” Gopalakrishna says. “Tooth loss due to dental caries or a periodontal condition can impact the overall well-being, including diet and nutrition. Therefore, prevention of oral diseases and routine oral care would be ideal approaches.”

— Michele Deppe is a freelance writer based in South Carolina.


1. Hidden tooth infections increase heart disease risk by almost three times. UPMC Western Maryland website. Published February 18, 2018. Accessed February 20, 2023.

2. Facts about older adult oral health. Centers for Disease Control and Prevention website. Updated May 5, 2021.

3. National Institute of Dental and Craniofacial Research. Dry mouth & older adults. Published August 2018.

4. Coll PP, Lindsay A, Meng J, et al. The prevention of infections in older adults: oral health. J Am Geriatr Soc. 2020;68(2):411-416.

5. Garcia B, King-Patel M. New recommendations for antibiotic prophylaxis prior to dental procedures. Contagion Live. Published August 5, 2021. Accessed February 10, 2023.

6. Julkunen L, Hiltunen K, Kautiainen H, Saarela RKT, Pitkälä KH, Mäntylä P. Oral disease burden of dentate older adults living in long-term care facilities: FINORAL study. BMC Oral Health. 2021;21(1):624.

7. Gao SS, Chu CH, Young FYF. Integrating 5S methodology into oral hygiene practice for elderly with Alzheimer’s disease. Dent J (Basel). 2020;8(2):29.

8. Müller F. Oral hygiene reduces the mortality from aspiration pneumonia in frail elders. J Dent Res. 2015;94(3 Suppl):14S-16S.

9. Qiao Y, Wang Z, Li Y, Han Y, Zhou Y, Cao X. Rheumatoid arthritis risk in periodontitis patients: a systematic review and meta-analysis. Joint Bone Spine. 2020;87(6):556-564.

10. Calderaro DC, Corrêa JD, Ferreira GA, et al. Influence of periodontal treatment on rheumatoid arthritis: a systematic review and meta-analysis. Rev Bras Reumatol Engl Ed. 2017;57(3):238-244.

11. Chen C-K, Wu-T, Chang Y-C. Periodontal inflammatory disease is associated with the risk of Parkinson’s disease: a population-based retrospective matched-cohort study. PeerJ. 2017;5:e3647.

12. Friedlander AH, Mahler M, Norman KKM, Ettinger RL. Parkinson disease: systemic and orofacial manifestations, medical and dental management. J Am Dent Assoc. 2009;140(6):658-669.

13. Depression is not a normal part of growing older. Centers for Disease Control and Prevention website. Updated September 14, 2022. Accessed Feb. 1, 2023.

14. Cademartori MG, Gastal MT, Nascimento GG, Demarco FF, Corrêa MB. Is depression associated with oral health outcomes in adults and elders? A systematic review and meta-analysis. Clin Oral Investig. 2018;22(8):2685-2702.

15. Fang W-L, Jiang M-J, Gu B-B, et al. Tooth loss as a risk factor for dementia: systematic review and meta-analysis of 21 observational studies. BMC Psychiatry. 2018;18(1):345.

16. Oh B, Han D-H, Han K-T, et al. Association between residual teeth number in later life and incidence of dementia: a systematic review and meta-analysis. BMC Geriatr. 2018;18(1):48.

17. Lamster IB, Asadourian L, Del Carmen T, Friedman PK. The aging mouth: differentiating normal aging from disease. Periodontol 2000. 2016;72(1):96-107.

18. Carvalho TS, Lussi A. Age-related morphological, histological and functional changes in teeth. J Oral Rehabil. 2017;44(4):291-298.

19. Dibello V, Zupo R, Sardone R, et al. Oral frailty and its determinants in older age: a systematic review. Lancet Healthy Longev. 2021;2(8):e507-e520.

20. Halpern LR. The geriatric syndrome and oral health: navigating oral disease treatment strategies in the elderly. Dent Clin North Am. 2020;64(1):209-228.