Mr Vaithilingam Satkunarajah sought help at Khoo Teck Puat Hospital (KTPH) in 2015 when his dentures became loose and felt uncomfortable, rendering him unable to speak or eat well. 

A dental check showed that he had many badly decayed teeth. He extracted nine over multiple visits, and some were saved with fillings. He had a new set of dentures made, motivating him to take better care of his teeth. 

But around 2019, when his Parkinson’s disease worsened, his oral hygiene suffered. His previously filled teeth had decayed again, and he had to have another four extractions.

Several factors associated with Parkinson’s disease can contribute to a higher risk of dental problems, says Dr Sophia Yee, a registrar at KTPH’s dental surgery department. She has been seeing the 75-year-old for follow-up checks every three to four months. 

The disease, which is a neurodegenerative disorder, can affect hand dexterity and coordination, making it challenging for people to brush and floss effectively. 

As the disease worsens with time, Dr Yee assesses Mr Vaithilingam’s hand dexterity and oral hygiene at every visit.

She gets him to remove and insert his dentures to assess his hand movements and observes if he is able to do it with ease. Occasionally, she asks him to squeeze both her index and middle fingers together to gauge his hand grip strength, to check if he is able to properly grip the handle of a toothbrush. 

Despite the tremors and reduced strength in his hand, Mr Vaithilingam, a retired engineer, still makes it a point to brush his teeth twice daily using an electric toothbrush. He also uses mouthwash. 

“Some young people may think it’s not important to take care of their teeth, but as we grow older, problems can set in due to our bad habits over the years,” says Mr Vaithilingam, who is married and has two children aged 38 and 33.

As Singapore faces a rapidly ageing population, a higher prevalence of dental health issues is expected, say dentists. 

Common dental problems among older adults include tooth decay, gum disease and tooth loss, largely due to a lifetime of dental wear, poor oral hygiene and dry mouth. 

Dr Yang Jingrong, who heads the National Dental Centre Singapore’s (NDCS) Geriatric Special Care Dentistry Clinic and is a consultant with the Restorative Dentistry department, says older adults typically have dry mouth due to the intake of multiple medications. 

A dry mouth reduces saliva production, which plays a crucial role in rinsing away food particles, neutralising acids and protecting teeth from decay. Without enough saliva, the mouth can become more susceptible to bacterial growth and tooth decay, adds Dr Yang.

Mr Siriniwas, who goes by only one name, has a dry mouth, which requires him to take sips of water now and then. 

The 74-year-old is retired and used to work as a security officer. He has idiopathic pulmonary fibrosis – a disease that causes scarring of the lungs – hypertension, high cholesterol and diabetes. He takes many medications daily. 

Drinking enough water to combat thirst is one effective option to reduce the sensation of a dry mouth, says Dr Yang.

Besides using a toothpaste containing fluoride to protect against tooth decay, hydrating mouthwashes and mouth gels can also help with the condition, she adds. 

Mr Siriniwas first visited KTPH’s Dr Yee in 2020 to treat an infection around a dental implant that had been done over 20 years ago at a private clinic. He also underwent root canal treatment for several teeth and received a set of dentures.

“Taking care of my teeth didn’t feel important,” he says. 

“I had poor oral hygiene for the majority of my life. I smoked and quit only six years ago when I was told I had idiopathic pulmonary fibrosis,” says Mr Siriniwas, who is married and has three teenage children. 

People who smoke are at higher risk of developing gum problems, decay on the roots of teeth, and losing teeth.

People’s gums, Dr Yee says, recede with age, and expose the roots of the teeth. This can cause sensitivity or increase the risk of decay around the roots. 

Ageing can also lead to decreased height and density of the jawbone, and a loss of elasticity of soft tissues in the mouth. This can affect the use of dentures as they become more unstable and loose when the bone is diminished, she notes. 

Dentures that are loose or feel painful is a common problem among older adults. 

In 2019, Madam Long Geok Chan felt uncomfortable eating when her dentures were not fitting well. “I knew I had to do something because the dentures were moving when I was eating,” says the 83-year-old retiree.

The former nurse went to Dr Yee, who fabricated a new set of dentures for her. Now, she can eat food such as char siew and satay without problems. 

Dental surgeon Samintharaj Kumar, chief executive of Nuffield Holdings, recalls an 88-year-old patient who found it a challenge to eat due to the discomfort caused by her dentures.

She underwent the All-on-4 implant procedure, which restored her ability to enjoy hard foods and significantly boosted her confidence and smile, says Dr Kumar.

The procedure is a solution for patients who need to replace all or most of their teeth, enabling them to leave the dentist with a new set of teeth on the same day. 

After the treatment, the patient’s nutritional intake improved, and within two months, she regained enough strength to walk unaided, no longer needing her walking stick, says Dr Kumar. 

“The patient’s daughter observed a dramatic shift in her mother’s attitude towards life. She became more upbeat and eager to socialise with friends,” he adds.

For people with limited hand dexterity, including those who have suffered a stroke or have Parkinson’s disease, maintaining oral hygiene can be challenging, says Dr Kumar. 

“Oral water irrigators are an excellent solution in such cases, as they effectively clean teeth and gums with a stream of water, which can complement traditional brushing and flossing,” he says. 

For seniors who are still able to hold a toothbrush, the dentist may suggest using an electric one or a toothbrush with a modified handle, says Dr Yang. 

Madam Long, for instance, uses a toothbrush with a head that is slightly bent so she can easily reach the innermost corners of her mouth.

While she still has a good grip, it is difficult for her to turn the toothbrush at an angle to reach her teeth in the back, so a bent toothbrush helps with that, says Dr Yee. 

Mr Vaithilingam uses an electric toothbrush due to limited hand dexterity and tremors in his hands brought on by Parkinson’s disease. Electric toothbrushes are useful because all one needs to do is guide the toothbrush along one’s teeth and gums, making them much easier to use for people with limited hand mobility or coordination.

They typically have powered brush heads that oscillate, rotate or vibrate to effectively remove plaque and debris from the teeth and gums, requiring less physical effort compared with manual toothbrushes. 

While electric toothbrushes are designed to do most of the work for you, it is important to use them correctly, highlights Dr Yee. 

“I have met patients who say they use electric toothbrushes, but their teeth are not very clean because they are using it wrongly,” she says.

Unlike manual brushing, where you move the brush in a circular movement, it is crucial to place the bristles of the electric toothbrush against the gums and teeth and to hold it in place for a few seconds before moving on to the next tooth, she notes. 

Though ageing affects the structure and function of teeth and gums, Dr Yee highlights that losing teeth is not part of natural ageing. With good oral care habits, it is possible to prevent tooth loss due to decay or gum disease. 

To maintain oral health, Dr Kumar says older adults should follow certain hygiene practices. These include using softer toothbrushes, and mouth rinses which contain chlorhexidine and fluoride, as they can help to kill or prevent the growth of bacteria in the mouth, as well as prevent decay.

Dr Yee has two patients aged 92 whom she has been seeing for dental checks every six months for the past three years. 

“They are immensely proud to have many of their natural teeth left and would often point to their teeth and say, ‘See, these are all real, not fake teeth,’” she says.

Bringing dental care to seniors

Going to the dentist may be difficult for some seniors, especially if they are cognitively impaired, using a wheelchair or bedbound. 

This is where the Tele-Dentistry Oral Care for Seniors (T-docs) programme by the NDCS comes in. 

The pilot programme was launched in 2021 with the aim of improving and maintaining the oral health of seniors in nursing homes and community hospitals, and those who are housebound.

Clinical Associate Professor Christina Sim is the principal investigator for the programme and a senior consultant at NDCS’ prosthodontics unit. She says the team works with five nursing homes, one home medical services provider and one community hospital, and has assisted nearly 300 seniors with oral checks. 

The majority of them have dental issues including cavities, periodontal disease and tooth loss. 

The nurses in the programme are trained to use an intraoral camera to take images of seniors’ teeth and gums. An intraoral camera is a small, handheld device used by dental professionals to capture high-quality images of the inside of a patient’s mouth.

The intraoral scans, along with the seniors’ medical information, are uploaded to an electronic system so dentists at NDCS can do a remote assessment. 

The findings and recommended treatment plan are then relayed back to the nursing staff at the community partners for follow-up with the seniors and their families. These include oral hygiene education and referrals to a dental practitioner of the seniors’ or family members’ choice for treatment. 

The programme is free for seniors, but does not cover the costs of any treatment that may be required.

The captured images also serve as a repository of oral health information, which can be analysed using an artificial intelligence (AI) software being developed to automate the interpretation of the images, says Prof Sim. 

The AI model, which is expected to roll out by 2025, will be able to alert dentists and nurses on problematic areas.

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