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Mandibular and Palatal Tori, Bone Mineral Density, and Salivary Cortisol in
Community-Dwelling Elderly Men and Women

Article  in  The Journals of Gerontology Series A Biological Sciences and Medical Sciences · December 2001
DOI: 10.1093/gerona/56.11.M731 · Source: PubMed

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Journal of Gerontology: MEDICAL SCIENCES Copyright 2001 by The Gerontological Society of America
2001, Vol. 56A, No. 11, M731–M735

Mandibular and Palatal Tori, Bone Mineral Density,

and Salivary Cortisol in Community-Dwelling Elderly
Men and Women
Jadwiga Hjertstedt,1 Edith A. Burns,2,3 Raymond Fleming,4 Hershel Raff,2,5 Inge Rudman,2,3
Edmund H. Duthie,2,3 and Charles R. Wilson6

1Division of Oral Medicine and Diagnostic Sciences, Marquette University School of Dentistry, Milwaukee, Wisconsin.
Departments of 2Medicine and 6Biophysics and Radiology, Medical College of Wisconsin, Milwaukee.
3Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin.
4Department of Psychology, University of Wisconsin-Milwaukee.
5Endocrine Research Laboratory, St. Luke’s Medical Center, Milwaukee, Wisconsin.

Background. This investigation evaluated the relationship between the presence of tori and bone mineral density
(BMD) and salivary cortisol levels.

Methods. A total of 230 healthy, community-dwelling elderly men (n  129) and women (n  101) aged 60 and
older participated in this study. Forty-three women were on hormone replacement therapy (HRT). This was a compo-
nent of a 5-year longitudinal study measuring subjects’ body composition, hormone levels, physical activity, and diet
every 6 months. Subjects were examined for the presence of tori by visual inspection and digital palpation. BMD at six
sites was measured by dual-energy X-ray absorptiometry. Salivary cortisol levels were measured by radioimmunoassay.

Results. Twenty-three percent of all subjects had mandibular tori, 13% had palatal tori, and 12% had both mandibu-
lar and palatal tori. Mandibular tori were more common in men, and palatal tori were more common in women. The
presence of mandibular tori was significantly correlated with BMD of the lumbar spine, femoral neck, trochanter, and
Ward’s triangle for all subjects, and with the femoral neck and trochanter of women not on HRT. Men with palatal tori
had lower levels of salivary cortisol in the evening.

Conclusions. This study documented the high prevalence of mandibular and palatal tori in a group of 230 elderly,
community-dwelling subjects. Women not on HRT and all subjects taken as a group with mandibular tori had higher
BMD. The presence of tori at young adulthood may be a marker of higher BMD in the future and of a lower risk for de-
veloping osteoporosis.

M ANDIBULAR and palatal tori were first described

more than 100 years ago in the anthropological litera-
ture (1,2). They are considered to be relatively rare but nor-
mal anatomic formations. These benign bony hyperostoses
are asymptomatic and begin to be clinically visible in the
second decade of life (3); they cease growing or exhibit
only minimal growth after the fourth decade (4). There are
no longitudinal studies to suggest that they resorb over time.
Mandibular tori (MT), usually bilateral, are located on the
lingual aspect of the mandible above the mylohyoid ridge
(5,6) (Figure 1). Palatal tori (PT) present symmetrically
along the mid-suture line of the hard palate. Tori consist of
normal cancellous bone covered by a layer of cortical bone.
They vary in size, can be flat or lobular, and can present as
solitary nodules or multiple nodular masses that coalesce.
Their etiology is not fully understood, but hereditary and
functional or environmental factors, such as masticatory
stress, have been implicated in their manifestation (5,7).
Osteoporosis is a major health problem in the aging pop-
ulation, manifesting as structural bone changes, loss of bone
mass, and increased incidence of fractures (8–11). Skeletal
bone mass reaches its peak in the early thirties and declines
with age. The onset of decline in bone mineral density
(BMD) in women occurs at an earlier age than in men, al-
though individual variations in the rate and degree of loss
are considerable (12). The peak BMD and rate of change of
BMD vary at different skeletal sites depending on the ratio
of trabecular to cortical bone and on the average use at the
site (12). Numerous factors can affect BMD and the devel-
opment of osteoporosis, including extrinsic factors such as
nutrition, medication use, amount of physical activity, life-
style factors (e.g., smoking and alcohol abuse), and intrinsic
factors (e.g., adrenal and gonadal hormone levels). The rela-
tionship between BMD and estrogen levels in women has
been extensively studied, and an accelerated rate of BMD
loss occurs during the immediate post-menopausal period
(13). In men, a somewhat later and more gradual loss of
BMD has been associated with declining endogenous an-
drogen levels (10,14,15). We (16) and others (17–22) have
also recently reported an association between age and eleva-
tions in nadir cortisol levels. Our study also found a rela-
tionship between higher nadir salivary cortisol and lower
BMD in men and in women who have not used hormone re-
placement therapy (HRT) (16).

M731
M732 HJERTSTEDT ET AL.

Veterans Affairs Medical Center. Subjects were recruited

Figure 1. Photograph of bilateral mandibular torus. The bony hy-
perostoses are located on the lingual aspect of the mandible, poste-
rior to the canines. Note the presence of a second hyperostosis poste-
riorly on the left.
from a group of community-dwelling men and women from
southeastern Wisconsin (60 years of age) participating in
a study of body composition changes with age that was
funded by the National Institute on Aging. Data on eco-
nomic status, years of education, smoking, and baseline di-
etary status have been described elsewhere (32). Excluded
from the study were those with symptomatic chronic dis-
ease of any organ system other than glaucoma, cataracts,
hypertension, treated idiopathic hypothyroidism, and de-
generative joint disease. Specific exclusionary criteria were
body weight 85% and 120% of ideal, recent weight
change of more than 5 pounds, presence of diabetes melli-
tus, a Folstein Mini-Mental State Examination score below
25, and the use of prescription medications other than anti-
histamines, non-narcotic analgesics, antihypertensives, and
thyroid or hormone replacement therapy. All subjects
signed a separate consent form to participate in the dental
component of the study and were informed that not partici-
pating in the dental/oral component would not influence
their participation in the ongoing project.

As with other bones in the skeleton, mandibular BMD de- BMD

creases with age (23–27). In a cross-sectional study of 85 os-
teoporotic women and 27 normal women, Kribbs and col-
leagues (25,26) demonstrated decreased mandibular BMD
and a thinner cortex at the gonion in osteoporotic women.
Another study reported greater cortical bone width and over-
all BMD of the mandible in men compared with women and
declining BMD in both genders after age 50 (28). Autopsy
studies have found an inverse correlation between mandibu-
lar BMD and age, with lower values found in women com-
pared with men at all ages (29–31). Because tori appear to
stop growing at approximately the time that peak BMD is
reached, we hypothesized that the two phenomena might be
interrelated. We are unaware of any studies evaluating the
relationship between tori and BMD. The purpose of this
study was to evaluate the relationship between the presence
of tori and BMD and salivary cortisol levels in a group of
community-dwelling elderly men and women.
Skeletal BMD was measured by dual-energy X-ray ab-
sorptiometry (DXA; Norland XR26, Fort Atkinson, WI) at
six sites: the proximal and distal radius, the lumbar spine
(L2–4), the femoral neck, Ward’s triangle, and the intertro-
chanter region. Measurements were obtained every 6
months over a 5-year period.
Oral Examination
All subjects were examined at the 4-year point of the 5-year
longitudinal study. A single investigator (J.H.), blinded to
other data (e.g., hormone use and BMD), performed all
oral assessments, eliminating the risk of inter-examiner er-
ror. Visual inspection and careful digital palpation deter-
mined the presence or absence of MT and PT. No distinc-
tion was made regarding the size or shape of tori. When
applicable, subjects were asked to take out removable den-
tures before the oral examination.

METHODS Salivary Cortisol Levels

Cortisol levels were measured in saliva obtained at 11 pm
Subjects (nadir in circadian rhythm) and 7 am (peak in circadian
The study was approved by the institutional review rhythm) at the 4-year point of the study. Subjects collected
boards of the Medical College of Wisconsin and Zablocki evening saliva at home and returned the samples for pro-

Table 1. Prevalence of Mandibular and Palatal Tori in 230 Elderly Subjects

HRT Women HRT Women All Women Men All Subjects
Group n (%) n (%) n (%) n (%) n (%)
Total sample 58 43 101 129 230
MT only 11 (19) 7 (16) 18 (18) 35 (27) 53 (23)
PT only* 12 (21) 8 (19) 20 (20) 9 (7) 29 (13)
Both 10 (17) 6 (14) 16 (16) 12 (9) 28 (12)
None 25 (43) 22 (51) 47 (47) 73 (57) 120 (52)

Notes: Numbers in parentheses in columns 2 through 5 represent the percentage of subjects in the gender group who did or did not have the indicated bone forma-
tion. Numbers in parentheses in the last column represent the percentage of all subjects with the indicated bone formation. HRT  not using hormone replacement
therapy; HRT  using hormone replacement therapy; MT  mandibular torus, PT  palatal torus.
*p  .05 comparing frequencies between men and women.
 TORI AND BONE MINERAL DENSITY M733

Table 2. Mean Bone Mineral Density by Gender and Hormone Use than 10% were current smokers. The average length of time
at Year 4 (Phase 8) smoked was 22  2 years, and the average amount smoked
HRT Women HRT Women Men was 27  3 pack years.
Table 1 shows the prevalence of mandibular and palatal
BMD BMD BMD tori in this group of men and women. The presence of tori
Site (g/cm2) SD (g/cm2) SD (g/cm2) SD
was unrelated to age. The percentage of all subjects with
L2–4 0.904 0.021 1.018 0.025 1.174 0.019 only mandibular tori was 23% (53/230), the percentage with
Femoral neck 0.711 0.013 0.762 0.016 0.844 0.013 only palatal tori was 12.6% (29/230), and the percentage
Ward’s triangle 0.514 0.014 0.560 0.016 0.574 0.012
with both was 12.2% (28/230). MT only were present in
Trochanter 0.562 0.015 0.616 0.018 0.789 0.013
Proximal radius 0.238 0.006 0.277 0.007 0.371 0.006 27% of men and 18% of women (not significant). PT only
Distal radius 0.557 0.011 0.633 0.011 0.799 0.008 were significantly more common in women than in men
(20% vs 7%; 2  7.34, p  .01). The presence of tori in
Note: HRT  not using hormone replacement therapy; HRT  using
both locations occurred in 15.8% of women and 9.3% of
hormone replacement therapy; BMD  bone mineral density; SD  standard
deviation; L2–4  lumbar spine. men (not significant).
Mean BMD was greater in men than women and greater
in HRT women than in HRT women at all sites (Table
cessing on the same day they collected morning saliva. Sa- 2). This pattern was observed not only at the time of oral ex-
liva was sampled by having subjects chew on a cotton roll amination but throughout the study. Table 3 shows the cor-
(Salivette; Sarstedt, Newton, NC) for 2 to 3 minutes or until relations between BMD and the presence of mandibular
the cotton roll was soaked with saliva. Saliva was separated tori. For all subjects, the presence of mandibular tori was
from the cotton roll by centrifugation and then frozen. Sali- significantly correlated with BMD at the lumbar spine, fem-
vary cortisol concentration was measured by radioimmu- oral neck, trochanter, and Ward’s triangle. For HRT
noassay as previously described (33). The minimal detect- women, the presence of mandibular tori was directly and
able level was 0.4 nmol/l, and the interassay coefficient of significantly correlated with BMD at the femoral neck and
variation was 6% to 12%. trochanter site (Table 3). Because these subjects had been
involved in the longitudinal study for 4 years prior to oral
Data Analysis and Statistics examination, we wished to examine the relationship be-
Descriptive statistics, Pearson’s correlation coefficients, tween the presence of tori and BMD at baseline. For HRT
one-way analysis of variance (ANOVA), repeated measures women, the presence of mandibular tori correlated with
ANOVA, and categorical ANOVA were performed using Ex- BMD at the femoral neck 4 years earlier (r  .33, p  .02).
cel 7.0 (Microsoft, Redmond, WA) for personal computers and There were no significant correlations between the presence
SPSS for OSF/1, Release 6.1 (SPSS, Chicago, IL) software. A of tori and baseline BMD for HRT women or for men. No
p value of .05 was considered statistically significant. significant correlations were present between BMD of the
proximal and distal radius and mandibular tori in any group.
RESULTS Table 4 shows the correlations between BMD and the pres-
A total of 230 subjects agreed to participate in the oral/ ence of palatal tori. For all subjects combined, the presence
dental component. There were 129 men (aged 71  4 years, of a palatal torus was inversely related to BMD only at the
mean  SD) and 101 women (aged 70  4 years). At study proximal radius (r  .144, p  .041) and at the distal ra-
entry, 43 women were on hormone replacement therapy dius (r  .190, p  .007).
(HRT) and had been taking estrogen for at least 1 year,
and 58 women were not taking HRT (HRT). HRT were Salivary Cortisol, Tori, and BMD
somewhat younger than HRT (69  4 years vs 71  5 In men, there was a significant inverse correlation be-
years; p  .05). Slightly less than 30% of the 230 subjects tween evening salivary cortisol levels and the presence of a
gave a past history of smoking (n  68), although fewer palatal torus (r  0.21, p  .02). In other words, men with

Table 3. Correlations Between the Presence of Mandibular Tori and Bone Mineral Density at Year 4
HRT Women HRT Women Men All Subjects

(n  52) (n  39) (n  112) (n  203)

BMD Site r Value p Value r Value p Value r Value p Value r Value p Value
L2–4 .26 .06 .10 .89 .16 .07 .17 .02*
Femoral neck .31 .03* .11 .68 .15 .11 .16 .02*
Ward’s triangle .17 .23 .17 .29 .14 .13 .16 .02*
Trochanter .29 .04* .22 .39 .14 .15 .14 .05*
Proximal radius .17 .23 .15 .35 .09 .35 .13 .07
Distal radius .25 .08 .14 .40 .03 .76 .11 .12

Notes: BMD  bone mineral density; HRT  not using hormone replacement therapy; HRT  using hormone replacement therapy; L2–4 lumber spine.
Numbers represent Pearson’s correlation coefficients between BMD at the indicated site and presence of mandibular tori, with significant p values in bold text. Num-
ber of subjects is less than number of total subjects in study because not everyone had a dual-energy X-ray absorptiometry done at the time.
*p  .05
M734 HJERTSTEDT ET AL.

Table 4. Correlations Between the Presence of Palatal Tori and Bone Mineral Density at Year 4
HRT Women HRT Women Men All Subjects

(n  52) (n  39) (n  112) (n  203)

BMD Site r Value p Value r Value p Value r Value p Value r Value p Value
L2–4 .08 .58 .06 .73 .16 .08 .03 .68
Femoral neck .05 .72 .18 .29 .09 .35 .08 .24
Ward’s triangle .12 .40 .09 .58 .10 .31 .04 .60
Trochanter .09 .52 .30 .06 .17 .07 .13 .07
Proximal radius .08 .58 .18 .28 .11 .24 .14 .04*
Distal radius .03 .84 .24 .14 .05 .58 .19 .01*

Notes: BMD  bone mineral density; HRT  not using hormone replacement therapy; HRT  using hormone replacement therapy; L2–4 lumber spine.
Numbers represent Pearson’s correlation coefficients between BMD at the indicated site and presence of palatal tori, with significant p values in bold text. Number of
subjects is less than number of total subjects in study because not everyone had a dual-energy X-ray absorptiometry done at the time.
*p  .05

a palatal torus had significantly lower nadir cortisol levels
than men without a palatal torus.
DISCUSSION
The primary purpose of this study was to investigate the
prevalence of tori and the relationship between mandibular
and palatal tori, BMD, and adrenal and gonadal hormones
in a group of community-dwelling elderly subjects. In this
group of initially healthy, predominantly Caucasian men
and women over the age of 65, more than 35% were found
to have mandibular tori. The prevalence of tori in this popu-
lation was at the high end of that reported in living popula-
tions by other investigators. In these studies, certain ethnic
groups displayed high frequencies of tori (Eskimos and
Aleuts) compared with low frequencies in Caucasians, Afri-
can Americans, and Asians (5,4,34,35,36). Higher frequen-
cies have been reported in studies of skeletal remains, per-
haps due to the mode of examination (5,37). Previous reports
also found a higher frequency of palatal tori compared with
mandibular tori (4,34). By contrast, the present study found
a higher frequency of mandibular tori with no difference be-
tween genders. Palatal tori were more common in women.
As expected, BMD was higher in men than women, and
higher in HRT women than HRT women. There were
significant positive correlations between the presence of
mandibular tori and BMD for all subjects and for HRT
women. There was a significant negative correlation be-
tween evening salivary cortisol and palatal tori in men. As
we have recently described, men with higher salivary corti-
sol levels had lower BMD (16). The rate of bone loss was
similar for all subjects regardless of the presence or absence
of tori, gender, or use of HRT. The presence of tori appears
to be an indicator of denser skeletal mass in HRT women
and in the group as a whole. The subgroup of HRT
women had significantly greater BMD, and this relationship
appeared to override the significance of tori as an indicator
of higher bone density. It should be emphasized that these
correlations, although statistically significant, were quite
low, as would be expected when many other factors are
likely to be stronger predictors of BMD.
The underlying etiology of tori remains unclear, and it is
also uncertain if mandibular and palatal tori share the same
etiology. Little is known about the potential significance of
tori for oral or general health. This is the first study to de-
scribe a significant relationship between mandibular tori
and BMD. Women who were not using HRT who also had
mandibular tori had significantly higher BMD at the femo-
ral neck and trochanter. This suggests that the presence of
mandibular tori early in life may be of prognostic value for
the natural history of BMD loss in women after menopause.
The presence of tori in young adulthood may be a marker of
higher peak BMD in the future and may possibly indicate a
lower risk for developing osteoporosis at more advanced
ages. The presence of palatal tori may also predict patterns
of cortisol dynamics with aging.
Acknowledgments
This study was supported by NIH/NIA Grant AG 12010-10, the Veter-
ans Affairs Research Service, GCRC Grant M01 RR00058-38, and St.
Luke’s Medical Center.
We thank Dr. Dale E. Mattson for help with the initial statistical analyses.
Address correspondence to Dr. Jadwiga Hjertstedt, Division of Oral
Medicine and Diagnostic Sciences, Marquette University School of Den-
tistry, P.O. Box 1881, Milwaukee, WI 53201-1881. E-mail: Jadwiga.
Hjertstedt@marquette.edu
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Received July 25, 2000
Accepted December 5, 2000
Decision Editor: John E. Morley, MB, BCh