While the number of Americans who are 65 years of age or older will increase dramatically in the coming years, it is predicted that another age group will more than double. The number of Americans older than 85 years of age is expected to more than double from 6.5 million in 2018 to 14.4 million by the year 2040 [5].

Some studies have found periodontal microbes in arterial plaques associated with the narrowing of vessels, the beginning of atherosclerosis, and even the initiation of blood clots [14]. Chronically inflamed gingival tissues can increase the amount of C-reactive protein found in the blood, an indicator of systemic inflammation [15]. This compound is also elevated in patients with cardiovascular disease.

Another substance that is elevated amidst the chronic inflammatory process of periodontitis is fibrinogen [15]. This is a high-molecular-weight compound that, in the presence of thrombin and clotting factors, is converted to fibrin, which is the basis for the coagulation of blood. While a necessity for hemostasis, this mechanism can become problematic within blood vessels when a thrombus, or localized clot, develops and occludes a blood vessel. Depending on the vessel involved, a stroke or myocardial infarction can develop. The periodontal bacterial species Porphyromonas gingivalis has the potential to initiate the clotting process [16].

Patients with chronic periodontitis also exhibit increased levels of tumor necrosis factor-alpha. Heightened amounts of this substance in the body can cause the liver to increase the production of triglycerides and decrease the amount of high-density lipoprotein, the beneficial cholesterol [15]. The elevation of one known risk factor and the lowering of a beneficial cardioprotective compound can increase the risk of the development of cardiovascular disease.

The Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure classified systolic and diastolic blood pressure numerical values with categories that reflect a philosophy for earlier intervention; these defined values were supported by a 2014 update [19]. In 2018, the American College of Cardiology, in conjunction with the American Heart Association and many other organizations, released updated guidelines for the prevention, detection, evaluation, and management of high blood pressure in adults [20]. In this guideline, the values assigning various stages of hypertension were significantly lowered. Elevated blood pressure is defined as a sustained systolic blood pressure between 120–129 mm Hg and a sustained diastolic blood pressure less than 80 mm Hg. When the systolic levels range from 130–139 mm Hg and the diastolic levels are 80–89 mm Hg, the categorization of stage 1 hypertension is assigned. Stage 2 hypertension occurs when the systolic blood pressure exceeds 140 mm Hg and the diastolic blood pressure exceeds 90 mm Hg. Certain co-existing diseases can modify this scale [20,21]. As many patients with high blood pressure also have other cardiovascular or cerebrovascular problems, proper medical management of this disease is essential to preventing associated morbidity and mortality.

Approximately 90% of hypertension cases have no known exact etiology; this is referred to as essential hypertension. The remaining cases are classified as secondary hypertension; in these patients, an underlying medical problem or a prescribed medication is the cause of elevated blood pressure levels [22]. Oral contraceptives, renal disease, and endocrine problems such as hyperthyroidism are among the most common causes of secondary hypertension. Certain tumors, such as a pheochromocytoma, although uncommon, can also be the basis for secondary hypertension. Pheochromocytoma is a tumor of the adrenal medulla that can cause the secretion of large amounts of the vasoconstrictors epinephrine and norepinephrine, which can cause a profound elevation in blood pressure.

Calcium channel blockers (e.g., nifedipine) exert their effects by decreasing the entry of calcium into the smooth muscle within arteriolar walls. The ensuing muscular relaxation and vessel dilation causes a reduction in blood pressure. Calcium channel blockers can also cause a decrease in sodium, which decreases water resorption, blood volume, and blood pressure.

A unique oral side effect of nifedipine, seen in approximately 10% of patients, is gingival hyperplasia. This can occur within a few weeks to several months after nifedipine therapy is begun. Gingival tissues should begin to regress after the drug is discontinued, with full resolution in approximately 15 days [26]. However, resuming use of the drug generally results in recurrence of the disorder unless additional steps are taken.

Cardiovascular disease affects one-third of people 65 years of age or older [28]. Of all deaths caused by ischemic heart disease, approximately 64% are in individuals older than 75 years of age [28]. Ischemia occurs when an obstruction within a blood vessel interrupts the flow of oxygenated blood needed to meet the metabolic demands in a given tissue, such as the myocardium of the heart. If the reduction of oxygenated blood weakens the myocardial cells but does not cause their necrosis, the resulting chest pain is known as angina pectoris. If the degree of ischemia is enough to cause necrosis of the myocardial cells, then a myocardial infarction occurs.

Angina is classified according to the degree of cardiac stability with which the patient presents. Stable angina refers to chest pain that occurs infrequently, usually when physical exertion and/or emotional stress cause the metabolic demand of the myocardial tissues to exceed the available supply of oxygenated blood provided by the cardiac circulation. The pain is relieved by a sublingual spray or tablet of nitroglycerin. If the frequency and/or intensity of angina attacks increases when the patient is at rest, unstable angina has developed.

Anticoagulant medications exert their effects either by modifying platelet function or by interfering with the synthesis of coagulation factors. Aspirin and clopidogrel are examples of medications used in antiplatelet therapy. By contrast, warfarin is an anticoagulant and minimizes coagulation by interfering with the synthesis of vitamin K-dependent clotting factors II, VII, IX, and X within the liver [30].

The most frequently utilized platelet-inhibiting medication for prophylaxis against ischemic heart disease or a cardiovascular or cerebrovascular incident is aspirin [31]. As a single agent or combined with clopidogrel, aspirin acts to prevent the aggregation of platelets and increases bleeding time. Aspirin ultimately interferes with the release of thromboxane A2, a substance that is responsible for platelet aggregation [31]. This effect lasts for the 10-day average life span of any platelet affected. Clopidogrel acts by blocking adenosine diphosphate (ADP) receptors on the platelet membrane, inhibiting platelet aggregation [31].

Prior to any dental treatment, especially oral surgery or periodontal treatment, the reason for which the patient has been placed on anticoagulant therapy should be discerned. If a dental procedure may affect hemostasis, the best route of action should be discussed with the patient's physician. The patient's prothrombin time should be noted. Prothrombin time is reported as an international normalized ratio (INR). The INR is a ratio of the prothrombin time for the patient and a control and is based on a scale of 1.0–5.0 [32]. An INR of 1.0 indicates a patient who clots normally. The target INR of patients who take anticoagulants depends upon the goals of treatment and underlying medical condition and can range from 2.0 to 3.5 [32]. If a surgical procedure is planned, an INR value should be obtained as close to the time of surgery as possible. Higher values are associated with more difficulty in obtaining hemostasis. It is important to determine if the patient's status allows for a temporary discontinuance of anticoagulant medication. In some cases, this is an option. However, the cardiovascular or cerebrovascular status of some patients may preclude the discontinuance of anticoagulant therapy due to the potential risks of a thromboembolic event. Those patients who cannot cease anticoagulant therapy may require that invasive treatment modalities, such as oral surgery, be performed in a hospital environment, especially when numerous teeth are involved. It is imperative that only a cardiologist or primary care physician with knowledge of the patient's condition direct the patient to stop anticoagulant or antiplatelet therapy. Patients should never stop taking anticoagulants on their own volition to expedite the completion of a surgical procedure.

Before any oral surgery or periodontal treatment is begun, compliance with the agreed upon regimen (e.g., discontinuance of anticoagulants) should be verified. Anticoagulant medications can interact with many medications. As noted, many medications prescribed for dental pain, including NSAIDs, can accentuate the anticoagulant effect of clopidogrel and warfarin. Additionally, macrolide antibiotics, such as erythromycin and clarithromycin, can attenuate the anticoagulant effect of clopidogrel but enhance this same activity for warfarin. It is essential that analgesics and/or antibiotics used for dental conditions do not enhance or detract from the intended effect of any anticoagulant medication.

Approximately 9% of Americans older than 65 years of age have a history of stroke, and 75% of all strokes occur in people older than 65 years of age [2,28]. Strokes are usually caused by atherosclerosis of the cerebral arteries, an aneurysm, or an embolism. Emboli or atherosclerotic plaques of the cerebral arteries can reduce or completely block the flow of oxygenated blood to brain cells. Similarly, a ruptured aneurysm causes damage to neurons by blood seeping into neural cells with a commensurate rise in intracranial pressure. These events may occur with no prior symptoms. However, some patients may experience transient ischemic attacks, which are characterized by sudden-onset, reversible neurologic deficits. Most transient ischemic attacks last less than five minutes. Nearly 1 in 5 patients who experience transient ischemic attacks progress to having an actual stroke within 90 days [33].

Two types of diabetes comprise the majority of diabetes cases in the United States: type 1 diabetes, previously referred to as insulin-dependent diabetes mellitus, and type 2 diabetes, which was previously known as non-insulin-dependent diabetes mellitus. Type 2 diabetes is responsible for more than 90% to 95% of all diabetes cases [34]. Approximately 22% of patients who present with type 2 diabetes are 65 years of age or older [35]. There are numerous systemic complications of diabetes, all of which contribute to it being the seventh leading cause of death in the United States [35,36].

Varied formulations of insulin are used to treat type 1 diabetes; type 2 diabetes is often managed with oral hypoglycemic agents, which may or may not be supplemented with insulin.

As a hormone, insulin is the only compound that lowers blood glucose levels. Insulin acts by hastening the transport of glucose into the cells, particularly skeletal muscle cells, and stimulating the formation of glycogen, the storage form of glucose, in the cells of the liver and skeletal muscle. It also decreases the rate by which glycogen is converted into glucose. The dosage schedule of insulin will depend upon the degree of hyperglycemia experienced by the patient.

Arthritis affects approximately 47% of individuals 65 years of age and older [49]. Osteoarthritis is the most common form of the disease, affecting approximately 32.5 million people in the United States [50]. Rheumatoid arthritis affects about 1.5 million people in the United States; 70% are women [51]. While the etiology of each form of arthritis is unknown, studies indicate that rheumatoid arthritis and periodontal disease may have a bidirectional relationship [52,53].

The types of arthritis manifest in different ways. Osteoarthritis usually occurs in weight-bearing joints such as the spine, hips, and knees; for this reason it is considered "wear-and-tear" arthritis. Cartilage in the arthritic joint degenerates over time, allowing two adjacent bones previously separated by a disc of cartilage to have direct bone-to-bone contact. Pain, joint stiffness, and restricted mobility can result.

Rheumatoid arthritis occurs when the synovial lining of a joint becomes swollen and thickened. Inflamed cells within the area can release enzymes that cause degeneration of the bone and cartilage. The shape of the involved joint can change with accompanying loss of function and pain. This disease can have periods of remissions and painful exacerbations, with the majority of the destruction occurring in the initial years. Most patients require long-term pharmacologic treatment to provide pain relief and allow for some function of the involved joints. The joints of the hands and wrists are most commonly affected [54]. Some patients with rheumatoid arthritis may develop arthritic degeneration of the temporomandibular joint. Treatment of rheumatoid arthritis of any joint may include splint therapy, physical therapy, and surgery. Unlike osteoarthritis, rheumatoid arthritis is a systemic disease and can result in generalized manifestations such as lethargy, malaise, and weakness.

The medications used to treat rheumatoid arthritis and osteoarthritis may have interactions with medications used for dental treatment. Additionally, some medications used in the treatment of arthritis may have adverse effects upon the oral mucosa.

Several NSAIDs are utilized to treat the inflammation characteristic of both forms of arthritis. Long-term administration of NSAIDs may prolong the ability to attain hemostasis after surgical procedures. Determination of prothrombin time may be helpful prior to planned surgical procedures.

Methotrexate is another medication used in the management of arthritic symptoms. When methotrexate is combined with NSAIDs for a sufficient duration, problems such as bone marrow suppression and aplastic anemia may develop [55]. Therefore, care should be taken to avoid the use of NSAIDs in these patients, if possible. Methotrexate may also cause oral ulcerations in some patients; ulcerations should resolve with discontinuance of the medication. The medication carries a boxed warning due to the increased risk for fetal abnormalities, bone marrow suppression, and hepatic and pulmonary side effects [55]. Gold sodium thiomalate, which is used to treat progressive rheumatoid arthritis, can cause gingivitis, glossitis, and stomatitis in some patients. This medication can also decrease both the white blood cell and platelet counts [26]. Therefore, a complete blood count should be obtained for patients using gold sodium thiomalate prior to surgical or periodontal procedures. Antibiotic prophylaxis is no longer recommended for all patients with prosthetic joint implants prior to dental procedures [56].

Hands and wrists that have been damaged by rheumatoid arthritis may have impaired dexterity, which can affect proper oral hygiene. Custom-modified toothbrushes and flossing aids can assist patients in maintaining oral health. If plaque accumulation is excessive, more frequent recall appointments will be necessary to minimize periodontal involvement and decrease the development of caries. If partial dentures are made for patients with arthritis, the design and placement of the clasps should be such that the placement and removal of these prostheses is facilitated. Because most patients with arthritis have joint stiffness and decreased mobility upon arising in the morning, appointments should be scheduled for late in the morning or the afternoon. Long appointments may be difficult for patients with arthritis to withstand, so those with extensive treatment plans may require a series of shorter appointments. The preventive approach to dental problems will assist in the maintenance of oral health, which will positively impact their quality of life.

Hands and wrists that have been damaged by rheumatoid arthritis may have impaired dexterity, which can affect proper oral hygiene. Custom-modified toothbrushes and flossing aids can assist patients in maintaining oral health. If plaque accumulation is excessive, more frequent recall appointments will be necessary to minimize periodontal involvement and decrease the development of caries. If partial dentures are made for patients with arthritis, the design and placement of the clasps should be such that the placement and removal of these prostheses is facilitated. Because most patients with arthritis have joint stiffness and decreased mobility upon arising in the morning, appointments should be scheduled for late in the morning or the afternoon. Long appointments may be difficult for patients with arthritis to withstand, so those with extensive treatment plans may require a series of shorter appointments. The preventive approach to dental problems will assist in the maintenance of oral health, which will positively impact their quality of life.

Healthy bone metabolism is characterized by a delicate balance between bone formation and bone resorption. Osteoblasts are responsible for the formation of new bone during growth and repair; osteoclasts are the large multi-nucleated cells responsible for the resorption of bone. During the aging process, osteoblastic activity decreases, with an associated decrease in bone mass and an increased susceptibility to the fracture. Thus, bone metabolism will have a tendency toward bone resorption and bone weakening via osteoclastic activity. Oral bisphosphonates, such as risedronate and ibandronate, suppress the activity of osteoclasts and increase bone mineral density, thereby reducing the risk of fractures [63,64]. Intravenously administered bisphosphonates such as pamidronate and zoledronic acid are used to treat the pathologic resorption of bone that occurs with systemic malignancies such as multiple myeloma and metastasized breast cancer. More than 50% of intravenously administered bisphosphonate agents reach the bone. Due to the physiologic pH of the intestinal mucosa, only about 1% of oral bisphosphonates localize in the bone [65].

With the increased use of these agents has come a pathologic entity called medication-related osteonecrosis of the jaw (MRONJ), which develops in a small segment of patients who have taken bisphosphonates, antiresorptive (i.e., denosumab), or antiangiogenic treatments [64,66]. The exact process by which this condition develops is unknown. One possible explanation is that the decrease in osteoclastic activity with bisphosphonates may be of such magnitude that localized areas of damaged bone do not undergo the usual resorptive repair, resulting in necrotic sequestra of bone [67]. The true incidence of bisphosphonate-related MRONJ is unclear [66]. Although it is possible, patients with osteoporosis rarely require the high-dose IV bisphosphonates associated with the development of MRONJ. Patients undergoing treatment for multiple myeloma or metastasized breast cancer are much more likely to be administered bisphosphonates at the level required to initiate MRONJ [68].

Mucositis will resolve after radiotherapy is completed, with healing time proportionate to the extent of the lesions [77]. Only emergency dental treatment should be attempted while the patient is undergoing radiotherapy, and even this should be discussed with the patient's oncologist and surgeon.

Treatment for mucositis, as determined by the extent of the lesions, usually involves palliative care with non-narcotic or narcotic analgesics. Oral rinses such as benzydamine hydrochloride can provide limited temporary topical anesthesia for mucositis lesions. Oral rinses work best if they are initiated the day before radiotherapy begins. Patients should rinse, hold the analgesic against the afflicted areas for 30 seconds, then expectorate the excess. This protocol can be repeated three to four times daily, as needed [77]. Viscous lidocaine in a 2% solution may also be used three to four times daily. A dose of 5 cc of this solution is placed in contact with afflicted areas for 30 seconds to 1 minute, followed by the expectoration of any excess. Patients should be cautioned to avoid biting or traumatizing any tissue that is anesthetized; traumatic ulcers can develop and prolong the healing time. Patients with mucositis should be advised to remain on a cooler, softer diet that excludes foods with sharp edges. Hot, spicy, and acidic foods should not be consumed until the mucositis has resolved. Patients should be instructed to maintain optimal oral hygiene [77]. However, alcohol-based mouth rinses should be avoided due to the potential to irritate the lesions of mucositis. Established guidelines for oral care for patients in whom mucositis has developed include twice daily oral assessments (for hospitalized patients) and frequent oral care (i.e., minimum every four hours and at bedtime) that increases in frequency as the severity of mucositis increases [77].

The major salivary glands, including the bilateral parotid, submandibular, and sublingual, are very sensitive to ionizing radiation. Damage can occur to these glands with a cumulative dose of 10 Gy (1,000 cGy) radiation. When the cumulative dose of 54 Gy (5,400 cGy) has been reached, the secretory elements of the major salivary glands will have sustained irreversible damage [77]. If the malignancy occurs in the area of the parotid gland, which is a pure serous (watery secretion) gland, shielding techniques may not be able to prevent its subsequent damage. A higher degree of damage to this gland, with a subsequent loss of the serous component of saliva, causes the remaining saliva to be increasingly viscous. Patients with oral malignancies in which the primary beam of radiation minimizes or avoids damage to any or all of these glands are rare.

Unlike mucositis, salivary gland dysfunction, which is associated with higher cumulative doses of radiation, will not resolve after the cessation of radiotherapy. Eating, swallowing, speaking, and enjoying a good quality of life become difficult when the quantity and quality of saliva is diminished.

Serous secretions are important in the lubrication of the tissues. Oral soft tissues become more prone to damage when long-term desiccation occurs. Patients may have difficulty or be unable to wear dental prostheses on tissue that has become inadequately lubricated.

Interventions for xerostomia (dry mouth) include artificial saliva substitutes, frequent sips of water, or cholinergic medications, such as pilocarpine [77]. Unfortunately, cholinergic medications have minimal or no effect on salivary flow when severe damage from higher cumulative doses of radiotherapy has occurred. Immunoglobulins and other compounds present in saliva that support immune functions will have a decreased output and can subject patients to recurring opportunistic infections, such as oral candidiasis. Impaired salivary flow will also cause a decrease in saliva's cleansing action upon the teeth. Further, the ability of salivary components to maintain the pH of saliva as a mild base is altered, which causes the oral environment to become more acidic. This combination of effects can have devastating effect on teeth, resulting in radiation caries [77].

Radiation caries are characterized by a pattern of aggressive progression of dental caries on surfaces of teeth that are usually considered to be at a low risk for caries, such as the buccal (outer) and lingual (inner) surfaces of posterior teeth and the labial (outer) and lingual (inner) surfaces of anterior teeth. The incisal edges of anterior teeth and the cusp tips of the posterior teeth are also at increased risk for these caries. Teeth that are affected in this manner need not have pre-existing decay or existing restorations. Unfortunately, teeth afflicted with radiation caries can be difficult to restore and may eventually need to be extracted.

Among the deleterious effects of radiotherapy, the most severe is osteoradionecrosis (ORN). Ionizing radiation can cause deterioration of the vessels that supply oxygenated blood to the bones of the maxillary and mandibular arches. The resultant hypoxia can lead to the necrosis of osseous tissue unable to be protected from the primary beam of radiation. ORN occurs more frequently on the mandibular arch, which has less of a blood supply as compared to the maxillary arch [78].

Risk of ORN is directly related to radiation dose and the volume of tissue irradiated [78]. However, osteoradionecrosis can occur at any time after radiotherapy, and passage of time does not decrease the risk [78,79]. ORN is rare in patients who receive less than 60 Gy radiation therapy. The overall incidence of ORN has decreased from up to 11.8% in the last part of the 20th century to around 3.0% currently. However, the true frequency of ORN is impossible to determine because no mechanism exists for reporting the disease. More valuable than understanding the frequency is understanding the decrease in reparative capacity in tissue exposed to more than 60 Gy radiation [78]. Necrotic pieces of bone, which can have a considerable range in size, often break away from the affected bone and may emerge though the tissues. Small segments of bone can be removed with conservative surgical techniques, but large segments require extensive surgical resection. The development of osteoradionecrosis may be precipitated by trauma to the alveolar bone, as encountered with oral or periodontal surgery, odontogenic infections from periapical or periodontal pathology, or tissue irritation and subsequent ulceration that extends toward the bone. Patients who wear dentures or partial dentures may require the fabrication of new prostheses if this pathologic process dramatically alters the shape of the underlying supporting alveolar bone.

Unlike the localized effects of radiotherapy, chemotherapeutic drugs are administered systemically. These medications are utilized to target the rapidly dividing cells found in malignant lesions. Unfortunately, these medications also target healthy, rapidly dividing cells, such as those of the oral mucosa and the hematopoietic cells of the bone marrow. The resultant problems of mucositis and a compromised immune system can develop. Approximately 40% of patients who receive chemotherapy will develop mucositis [80]. About one-half of these patients will experience mucositis that is severe enough to postpone or modify the chemotherapeutic regimen [81].

Management of chemotherapy-related oral complications include oral debridement and decontamination, topical and systemic pain management, prophylaxis (e.g., sucking ice chips), antiviral medications, and control of bleeding [82]. Medications used to treat the mucositis of patients with oral cancer can also be used for those undergoing chemotherapy.

Upon the cessation of chemotherapy, most cases of mucositis will resolve and, in general, the production of normal levels of hematopoietic cells will resume. However, some patients may experience chronic problems with either or both of these issues. Those who have had a bone marrow transplant will take immunosuppressive medications for the balance of their lives and can face chronic long-term problems with their immune system.

Muscle mass and total body water both decrease during the aging process, while total body fat increases. Thus, the distribution of water-soluble medications decreases, but distribution increases for lipid-soluble medications. Because water-soluble medications, such as acetaminophen, are distributed in a smaller volume of water, they are more concentrated in older patients as compared to the same dose in a younger patient. This results in an amplified effect of water-soluble medications in older adult patients [83]. Lipid-soluble medications, such as diazepam and lidocaine, are distributed throughout the greater volume of adipose tissue in older adults as compared to younger adults. This will have the effect of prolonging the actions of these medications, and dosages may need to be adjusted for optimal outcomes [84,85].

Age-related changes in the liver and the kidneys can also influence the metabolism and clearance of medications used in dentistry. The mass of the liver decreases approximately 1% per year in patients older than 40 years of age. Furthermore, the blood flow to the liver can decrease by 40% to 45% as the aging process continues [86]. These two conditions lead to a decrease in the hepatic metabolism of specific medications.

Increasing age is not automatically equated with decreasing salivary gland production and xerostomia, and secretions from the major salivary glands do not generally undergo a significant decrease in output during the aging process [87]. However, nearly 30% of patients 65 years of age or older experience xerostomia, most commonly medication-induced xerostomia [88]. There are an estimated 300,000 over-the-counter and more than 20,000 prescription medications available in the United States, and many list dry mouth as a possible side effect [89,90]. Medication-induced xerostomia can be a long-term problem for older patients, as they are more likely to be taking multiple medications for longer periods of time or indefinitely. Medications that decrease salivary production usually affect the unstimulated flow of saliva; saliva produced in response to a stimulus, such as food, remains unaffected [91].

Xerostomia can also be associated with certain diseases and their treatment modalities. The permanent problems that radiotherapy can directly cause to saliva production have been discussed. Similarly, chemotherapy can cause temporary disruptions to normal salivary flow. Systemic and autoimmune diseases, such as diabetes and Sjögren syndrome, can cause disruptions in the normal production of saliva.

Cognitive impairment may also cause oral hygiene problems. Estimates indicate that about 5% to 8% of individuals 65 years of age and older and 50% of patients 85 years of age and older have dementia [92]. Alzheimer disease is the origin of 60% to 80% of all dementia cases [92]. Dementia is the general term for a condition of progressive deterioration of brain function and eventual decline in intellectual capacity. In patients with dementia, abilities related to memory, thinking, and speaking all worsen over time. Individuals afflicted with Alzheimer disease often live for many years after the diagnosis. The initial stages of Alzheimer disease are characterized by subtle mild cognitive impairment that may not be readily apparent, even to family members.

The disease progresses at variable rates but ultimately leads to the inability to speak coherently or respond appropriately to stimuli within the local environment. Eventually, ambulation, mastication, and swallowing will become extremely difficult or impossible. Death usually ensues as a result of complications of the condition, such as aspiration pneumonia [93].

The oral health of patients diagnosed with Alzheimer disease can vary considerably. Patients who have maintained optimal oral health prior to their diagnosis will require minimal specialized dental treatment. Treatment to preserve oral health should reflect patients' ability to maintain proper oral hygiene, optimal periodontal health, and control of the development of carious lesions. Patients who have poor periodontal health and a high incidence of dental caries upon diagnosis of Alzheimer disease require a comprehensive dental exam and a specialized treatment plan.

Progression of Alzheimer disease usually leads to deterioration in oral health as the cognitive and neuromuscular elements essential for the basic skills for brushing and flossing continually diminish. Caregivers of patients with Alzheimer disease may have difficulty in performing these tasks. Further, with the advancement of the disease, patients may become less tolerant of and less cooperative with dental treatment. There will come a time when only emergency dental treatment performed under sedation is possible. Clinicians involved in the care of patients with Alzheimer disease may need to establish a protocol of more frequent periodic visits to monitor oral health.

If clinical presentation indicates poor oral hygiene and the rapid development of periodontal problems and dental caries between appointments, extractions should be considered; costly restorative treatment and periodontal therapy have a poor prognosis for success. If a patient is fitted for new dentures, the prosthesis should have the name of the patient placed in the acrylic. This is particularly important for institutionalized patients, as this step can help in the recovery of misplaced prostheses. Before surgical procedures are initiated, the patient's capacity to give informed consent should be determined and/or the healthcare proxies should be located.

Treatment of Alzheimer disease is generally palliative. However, patients in the initial stages of the disease may take antidepressants or antipsychotics to attenuate symptoms. Some of these medications can cause xerostomia and, by extension, oral hygiene problems.

Financing of dental care is the primary obstacle for many older adults. Most patients older than 65 years of age are retired and therefore no longer have dental insurance as an employee benefit. Without this option and income limited to retirement savings, social security income, and any pension plan benefits, the costs associated with dental treatment may not be easily accommodated. Funding from federal, state, and county sources is often limited, both in available funds and treatment coverage.

Available financial resources among the geriatric population vary considerably. Unfortunately, many older adults live near or even below the poverty level and have difficulty in affording basic preventive dental care.

Medical problems can also present as a major obstacle in the provision of dental care for older adult patients. As discussed, many older adults are afflicted with at least one chronic disease and most have experienced medical problems. Even with Medicare insurance, the cumulative costs of medical treatment and medications can escalate and contribute to budgetary concerns, making it difficult to afford dental care.

Coping with serious medical problems may leave older adults without the motivation and ability to seek dental care. Some medical problems may also lead to one spouse assuming the role of caretaker for the other. If this is the case, both can have difficulties in obtaining dental care. The caregiver spouse may have difficulty setting aside time for a dental appointment, while the morbidity of the medical problem and transport issues make dental appointments difficult for the infirmed. Patients in long-term care facilities may also face obstacles in obtaining dental care [99]. The cost of long-term care is often a strain and may limit patients' ability to afford dental treatment. Difficulties with transportation, especially to an outside dental office, may also be a barrier to seeking dental care. In order to overcome this barrier, some long-term care facilities may contract with a private dentist to provide care within the facility. However, the fees associated with this level of service are prohibitive to many.