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# **Relationship of Oral Health and Nutrition: Insights for the Aging Network**

*Bob is a 65-year-old veteran who lives in an apartment complex near a congregate site. Bob is embarrassed because of his decayed and missing teeth and doesn’t want to eat in a group setting with other seniors.*

*Mary is a 75-year-old widow who has diabetes. Because of her diabetes, she has developed gum (periodontal) disease.*

*Joe is 80 years old. He takes both prescription and over-the-counter drugs that cause dry mouth and reduce his saliva, which puts him at increased risk for cavities.*

*Sally is wearing dentures. She comes to the senior nutrition program but only eats soft, easily chewed foods instead of healthier choices like fresh fruits and vegetables.*

If you work at a senior congregate or home delivery site, you have seen Bob, Mary, Joe, and Sally in your centers. Good oral health is essential to overall health, but it has been overlooked in the aging population for years. 

The situations described above are prevalent among seniors. Nearly all adults 65 years and older have had a cavity (96%), and 1 in 5 have untreated tooth decay.[endnoteRef:2] About 2 in 3 adults 65 and older have gum disease (68%) and 1 in 5 have lost all of their teeth.[endnoteRef:3],[endnoteRef:4]    [2: Dye BA, Thornton-Evans G, Xianfen L, Iafolla TJ. Dental Caries and Tooth Loss in Adults in the United States, 2011-2012. NCHS Data Brief, no 197. Hyattsville, MD: National Center for Health Statistics; 2015.]  [3:  Colby SL, Ortman JM. Projections of the size and composition of the US Population: 2014 to 2060. Current Population Reports, P25-1143. Washington DC: US Census Bureau; 2014.]  [4:  Dye BA, Thornton-Evans G, Xianfen L, Iafolla TJ. Dental Caries and Tooth Loss in Adults in the United States, 2011-2012. NCHS Data Brief, no 197. Hyattsville, MD: National Center for Health Statistics; 2015.] 

In addition, around 85% of older adults have at least one chronic health condition, and 60% have at least two chronic conditions.[endnoteRef:5] People with chronic diseases such as arthritis, diabetes, heart disease, and chronic obstructive pulmonary disease (COPD) may be more likely to develop gum (periodontal) disease. Still, they are less likely to get dental care than adults without these chronic conditions.[endnoteRef:6] Also, most older adults take both prescription and over-the-counter drugs. Many of these medications cause dry mouth by reducing saliva flow that can lead to an increased risk of cavities.[endnoteRef:7] [5:  Centers forDisease Control and Prevention. Healthy Aging at a Glance 2011. Retrieved from: http://stacks.cdc.gov/view/cdc/22022]  [6:  Patel N, Fils-Aime R, Li C, Lin M, Robinson V. Prevalence of past-year dental visit among US adults aged 50 years or older, with selected chronic diseases, 2018. Prev Chronic Dis. 2021;18:200576. doi:http://dx.doi.org/10.5888/pcd18.200576.]  [7:  National Institute of Dental and Craniofacial Research. National Institutes of Health. Fact Sheet: Dry Mouth (Xerostomia) website. http://www.nidcr.nih.gov/OralHealth/Topics/DryMouth. Accessed July 5, 2016.] 

Older adults with low income and those who identify as racial/ethnic minorities tend to have poor oral health. Because health insurance benefits are often lost in retirement and Medicare does not cover routine dental care, they may also lack access to affordable dental health benefits.[endnoteRef:8] Older adults who live in institutions (e.g., nursing home), are homebound, or who are living with disabilities are also at higher risk of poor oral health.  [8:  7Colby SL, Ortman JM. Projections of the size and composition of the US Population: 2014 to 2060. Current Population Reports, P25-1143. Washington DC: US Census Bureau; 2014.] 

It has been found that adults receiving congregate and home-delivered meals (HDM) are older and in poorer health than the aging population as a whole and are more likely to live alone[endnoteRef:9]. The meals they receive through the HDM program may be the only hot and nutritious food they consume for the day. Oral health among this population is a challenging issue and can impact the ability of older adults to benefit from the nutritious food served.   [9:  Mathematica Policy Research. Needs of and Service Use Among Participants in the Older Americans Act Title III-C Nutrition Services Program 2018 Report. Retrieved from: https://acl.gov/sites/default/files/programs/2018-11/AoAParticipantNeedProgramUse.pdf] 

ACL’s Senior Nutrition Program (SNP) strives to help older adults remain healthy by providing regular, nutritious meals to those in greatest social and economic need[endnoteRef:10]. Meals served by the SNP are nutritious and must meet the current Dietary Guidelines for Americans, provide a minimum of 1⁄3 of the Dietary Reference Intakes, and be appealing to older adults. Older adults receive meals through a HDM program or through congregate and group settings (e.g., senior centers). [10:  ACL. Nutrition Services. Retrieved from: https://acl.gov/programs/health-wellness/nutrition-services] 

There is strong evidence connecting oral health to a healthy diet as well as overall health.[endnoteRef:11] Eating a variety of nutrient-rich foods from across the food groups promotes healthy teeth and gums. A balanced eating plan that includes fruits, vegetables, protein, grains, and dairy provides essential nutrients for maintaining oral health.  [11:  Importance of Oral Health Preventive Practices. Retrieved from: https://www.eatrightpro.org/news-center/on-the-pulse-of-public-policy/regulatory-comments/academy-highlights-importance-of-oral-health-preventive-practices] 

You can promote oral health among the older adults you serve by encouraging them to eat the following nutritious foods:

· Calcium-rich foods, such as low-fat or fat-free milk, yogurt and cheese, and fortified soymilk help promote strong teeth and bones. Other sources of calcium include tofu (made with calcium sulfate), canned salmon, almonds, and some dark green leafy vegetables.

· Phosphorus is a mineral found in eggs, fish, lean meat, dairy, nuts, and beans, and is essential for strong teeth.

· Vitamin C promotes gum health and is found in many sources, including citrus fruits, tomatoes, peppers, broccoli, potatoes, and spinach.

Studies show that the risk of malnutrition is greater in adults 60 years and older with tooth loss.[endnoteRef:12] Tooth loss—with and without replacement—affects eating behaviors and the overall eating experiences of adults, and ultimately impacts what food they eat. Older adults with tooth loss may require softer food choices for meals and snacks. To ensure they continue to get the nutrients they need, consider how to offer healthy foods in a variety of ways –for example, unsweetened apple sauce can be offered along with fresh apples and cooked carrots along with fresh carrots. [12:  Kikutani T, Yoshida M, Enoki H et al. Relationship between nutrition status and dental occlusion in community-dwelling frail elderly people. Geriatrics & Gerontology International. 2013;13(1):50–54.] 

Malnutrition has many warning signs, including not being able to eat or only being able to eat small amounts. You should screen clients for malnutrition with validated screening tools used by the aging network. These tools can help you determine whether any of your clients are suffering from malnutrition caused by poor oral health. Screening tools are easy to use and do not require formal nutrition training. 

Good oral health requires regular dental care. Encourage clients to schedule routine check-ups with their dental care provider. When clients are unable to pay for dental services, SNPs should connect them with resources in their community such as:

· **Community Health Clinics (CHCs)** – The Health Resources and Services Administration (HRSA) funds CHCs that care for older adults when they cannot pay for health care services. Many of these federally-funded health centers offer oral health care and can scale payment based on an individual’s income. 

· **Faith-Based Community Organization** – Some faith-based organizations also provide access to health and dental care for those in need. One example is Mission of Mercy, an independent nonprofit, faith-based community organization that provides free dental care to the uninsured and underinsured in several locations around the country.

· **Dental Schools** – Consider partnering with your local dental school to offer oral health screenings and dental care supplies (e.g., toothbrush, toothpaste, and floss) to your clients. Offer your program site as a location for students on community rotations so they can educate older adults on the importance of good oral health. Find a dental school in your area for more information.

· **Dental Hygiene Schools** – Dental hygiene schools may also offer low-cost, preventive dental care as part of the training experience for dental hygienists. To locate dental hygiene schools, visit the American Dental Hygienists’ Association website.

The aging network should regularly review internal policies to ensure they are serving those in greatest need, including those with poor oral health. These older adults may choose to stay at home because of their appearance or pain associated with oral health issues. Therefore, a prudent administrator may want to adjust their HDM policy to include this population in program services. 

*Updated December 2021*1

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