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Age-Related Oral Changes

Article  in  Dental update · October 2010

DOI: 10.12968/denu.2010.37.8.519 · Source: PubMed

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 Gerodontology

Gerald Mckenna

Francis M Burke

Age-Related Oral Changes

Abstract: Age-related oral changes are seen in the oral hard and soft tissues as well as in bone, the temporomandibular joints and the
oral mucosa. As older patients retain their natural teeth for longer, the clinical picture consists of normal physiological age changes in
combination with pathological and iatrogenic effects.
Clinical Relevance: With an ageing population retaining more of its natural teeth for longer, dental professionals should expect to observe
oral age changes more frequently.
Dent Update 2010; 37: 519–523

Worldwide population demographics

are changing rapidly and the proportion
of older people is growing faster than
any other age group. Approximately
600 million people are currently aged
60 years and over, and this number is
expected to double by 2025.1 Globally,
poor oral health among older people
has traditionally been manifest in high
levels of tooth loss, dental caries and
periodontal disease experience, as well
as xerostomia and oral precancer/cancer.2
In addition, evidence of the relationship
between oral health and poor general
health continues to grow with links
between severe periodontal disease and
diabetes mellitus, ischaemic heart disease
and chronic respiratory disease the focus
of much research.3,4
Age changes are manifest in
the oral and dental tissues. What is seen
is a combination of physiological age
changes with superimposed pathological
and iatrogenic effects.
Bone
Increasing age is associated
with progressive reduction in bone
Gerald Mckenna, BDS MFDS, Clinical
Research Fellow, HRB Scholar in Health
Services Research and Francis M Burke,
BDentSc, MSc, PhD, FDS FFD, Restorative
Dentistry, University College Cork, Ireland.
Figure 1. Extent of alveolar bone height following
loss of lower teeth.
mass resulting in osteoporosis.5 Age-
related osteoporosis is common and, in
edentulous patients, may play a role in
atrophy of alveolar and possibly basal
bone, although no clear relationship has
been established. Atrophy of alveolar bone
is related mainly to tooth loss (Figure 1). Its
extent increases with age resulting, in the Figure 2. Patient exhibiting loss of vertical face
absence of dentures, in loss of facial height height due to overclosure and posturing of the
with upwards and forwards posturing of mandible.
the mandible (Figure 2). Loss of alveolar
bone is more extensive and occurs more
rapidly in the mandible than in the maxilla
(Figure 3).
Levels of the cyclo-oxygenase
2 (COX 2) enzyme, which plays an essential
role in bone repair, decline dramatically
with ageing. This may explain the delayed
bone healing that occurs in older patients.
Research is now being conducted to
stimulate activity of the COX 2 enzyme
Figure 3. Atrophy of a lower edentate mandible.
and subsequent bone healing.6

October 2010 DentalUpdate 519

 Gerodontology
Figure 4. Chronic candidal infection under a full
upper prosthesis.
Temporomandibular Joint
(TMJ)
In the TMJ it is difficult to
distinguish changes due to ageing from
those related to osteoarthrosis. Excluding
those changes due to osteoarthrosis,
the main age changes are related to
remodelling of the articular surfaces and
disc in response to functional changes
following tooth loss. Remodelling may
result in disc displacement, particularly
anterior displacement. The retrodiscal
tissues may show adaptive changes
associated with decreased cellularity
and vascularity, and increased density of
collagen, and may eventually function as an
articular disc. However, in some cases the
displacement may lead to perforation of the
disc, particularly of its posterior attachment,
resulting in progressive joint damage.7
Nerves and musculature
Muscle function is dependent
on the performance of the nervous system
and both exhibit independent age-related
changes. Nerve cell loss is universal in old
age and is exhibited in the brain and spinal
cord. There are also age-related changes
in neurotransmitters, resulting in motor
dysfunction. Peripheral nerve function
declines with age as there is a reduction
in conduction velocity, increased latencies
in multi-synaptic pathways, decreased
conduction at neuromuscular junctions and
loss of receptors.8
Continued muscle function is
a major requirement for the maintenance
of speech and mastication. In all patients
with advancing age there is a reduction in
total muscle mass which occurs through a
520 DentalUpdate
Oral Trauma
n Burns, lacerations, chemical damage
n Anaesthetic administration
n Surgical trauma
n Removable prosthodontic appliances
Oral Diseases and Symptoms
n Caries
n Periodontal diseases
n Dento-alveolar infections
n Tooth loss
n Soft tissue lesions
n Candidosis, denture stomatitis
n Burning mouth syndrome
n Salivary dysfunction
n Impaired chewing
n Pain
Treatment of Oral and Systemic Diseases
n Oral mouthrinses, gels and toothpastes
n Drugs active in saliva
n Dental materials interactions
n Poor dental restorations, leaking restorations
n Chemotherapy
n Head and neck radiotherapy
n Oncological surgery
Table 1. Possible causes of olfactory and taste disorders.
reduction in the number of muscle fibres patients. However, changes over time
rather than a major reduction in muscle including mucosal trauma, mucosal
fibre size. Electrophysiological studies have diseases, and salivary gland hypofunction
also shown a loss of motor units with age, can alter the clinical appearance and
particularly in those over the age of 60 character of the oral tissues in older
years, which manifests as a reduction in patients.11
muscle strength and reduced masticatory The stratified squamous
forces. Age induces a lengthening of epithelium becomes thinner, loses
the chewing process associated with a elasticity, and atrophies with age. A
reduction in muscle activity, suggesting declining immunological responsiveness
that elderly patients adapt their chewing further increases the susceptibility to
behaviour to changes in chewing activity.9 infection and trauma. An increased
Evidence suggests that edentate incidence of oral and systemic disorders,
patients exhibit an increased reduction in along with increased use of medications,
muscle mass and a reduction in maximal may lead to oral mucosal disorders in
bite forces compared with dentate patients. elderly persons. Elderly patients may
However, many edentate individuals develop vesiculobullous, desquamative,
successfully rehabilitated using complete ulcerative, lichenoid and infectious lesions
dentures regard their masticatory function of the oral cavity (Figure 4).12 In addition,
as satisfactory.10 oral cancer is primarily a disease of ageing
and associated cell dysregulation. It is
estimated that more than 90% of all oral
Oral mucosa cancers in developed countries occur in
The clinical appearance of individuals older than 50 years, with a
the oral mucosa in older patients is often mean onset during the sixth decade of
indistinguishable from that of younger life. Oral cancer is associated with high
October 2010

morbidity and a particularly poor survival
rate of less than 50% after 5 years.13
Sensory changes
It is known that taste and smell
sensitivities change throughout life and
often decline with ageing. These changes
can make foods become tasteless thus
resulting in a reduction in appetite.14 Such
taste and smell dysfunctions may be due to
a variety of contributing factors including
oral diseases, systemic conditions and their
associated treatments (Table 1).15 Most
studies suggest that the sense of smell is
more impaired by ageing than the sense
of taste. Olfactory cells which respond to
smells are renewed much more slowly in
elderly people. Olfactory acuity declines
with age as the number of olfactory nuclei
in the brain decline and the olfactory
receptors in the roof of the nasal cavity
regress. As a result, older people generally
have greater difficulty differentiating
among food odours than younger people.
A diminution of taste results
from the degeneration of taste buds and a
reduction in their total number as renewal
is much slower in elderly people. Elderly
people have considerable differences in
their sensory perception and capacity to
detect the pleasantness of foods compared
with younger people.
This can lead to older people
adding ingredients such as sugars or salt
to foodstuffs which can have adverse
health effects. Whilst chemosensory deficits
experienced by elderly patients generally
cannot be reversed, interventions, including
intensification of the taste and odour of
foods, can compensate for age-related
perceptual losses. Amplified flavours
increase the number of molecules that
interact with receptors and compensate for
sensory losses. Evidence shows that such
amplification can improve food palatability
and acceptance, increase salivary flow and
immunity, and reduce oral complaints in
both sick and healthy older patients.16
Salivary glands
Complaints of a dry mouth
(xerostomia) and diminished salivary output
are common in older populations. Estimates
of xerostomia and salivary hypofunction
indicate that approximately 30% of the
October 2010
Figure 5. Evidence of gingival recession in an
elderly patient leading to exposure of root surfaces
and root caries.
population 65 years and older experience
these disorders and their accompanying
oral and pharyngeal consequences17,18
(Table 2).
Older adults experience dry
mouth for a variety of reasons. Interestingly,
output from the major salivary glands
does not undergo clinically significant
decrements in healthy older people.
As clinicians we should not attribute
complaints of a dry mouth in an older
person simply to their age: an appropriate
diagnosis is required.
The most common cause of
salivary disorders is the use of prescription
and non-prescription medications.
Reports indicate that 80% of the most
commonly prescribed medications can
cause xerostomia, with more than 400
medications associated with salivary gland
dysfunction as an adverse side-effect.19
Because elderly people are more likely
than the rest of the population to take
medications and are more vulnerable to
their side-effects, medication-induced
xerostomia is not uncommon.
Drugs with anticholinergic
effects are the most likely to produce
complaints of diminished salivary output
and dry mouth. Furthermore, drugs that
inhibit neurotransmitters from binding
to salivary gland membrane receptors, or
that perturb ion transport pathways in the
acinar cell, may adversely affect the quality
and quantity of salivary output. Common
categories of these drugs include:
n Tricyclic antidepressants;
n Sedatives and tranquillizers;
n Antihistamines;
n Antihypertensives;
n Cytotoxics; and
n Anti-Parkinsonism drugs.
Gerodontology
n Dental caries
n Dry lips
n Dry mouth
n Dysphagia
n Gingivitis
n Halitosis
n Problems with mastication
n Mucositis
n Oropharyngeal candidiasis
n Difficulty with removable prostheses
n Difficulty sleeping
n Difficulty with speech
n Traumatic oral lesions
Table 2. Oral and pharyngeal consequences of
salivary hypofunction.
One treatment for head and
neck cancers is external beam radiation,
which causes severe and permanent
salivary hypofunction and results in
persistent complaints of xerostomia.
Radiation-induced destruction of the
serous-producing salivary cells occurs via
apoptosis. Within one week of the start
of irradiation, a patient’s salivary output
may have declined by 60–90%, with no
recovery occurring unless the total dose
to salivary tissues is less than 25 Gy. Most
patients receive therapeutic dosages that
exceed 60 Gy, therefore their salivary
glands undergo atrophy and become
fibrotic.20
Numerous systemic medical
conditions, including:
n Sjögren’s syndrome;
n Diabetes mellitus;
n Alzheimer’s disease; and
n Dehydration
can cause or contribute
to salivary gland diseases. Sjögren’s
syndrome is one of the most frequently
encountered chronic autoimmune
connective tissue disorders and is the most
common systemic condition associated
with xerostomia. Sjögren’s syndrome
occurs in primary and secondary forms.
Those patients with primary Sjögren’s
syndrome have salivary and lacrimal
gland involvement, with an associated
decreased production of saliva and tears.
In secondary Sjögren’s syndrome, the
disorder presents with other autoimmune
diseases, such as rheumatoid arthritis,
systemic lupus erythematosis and
scleroderma.
DentalUpdate 521
 Gerodontology
Figure 6. Poor oral hygiene observed in an older
patient attending geriatric day hospital.
Figure 7.Toothwear of lower incisors in an elderly
patient (note the dentine deposition obliterating
the pulp chamber).
Figure 8. Staining of lower anterior teeth in an
elderly patient.
Figure 9. Pulp chambers of a 70-year-old patient
showing a reduction in depth of the pulp
chambers.
Periodontium
Epidemiological studies
show that the prevalence and severity of
periodontal disease increases with age.
522 DentalUpdate
This is most likely the result of repeated
episodes of active destruction occurring
over time rather than an intrinsic change
associated with the ageing process itself.
Periodontal changes attributable solely
to advancing age are not sufficient to
account for tooth loss, especially in a
healthy adult. Gingival recession has
been considered as an age change, but
it is now known to be part of the clinical
spectrum of periodontitis in which
plaque is the main aetiological agent
(Figure 5). There is no evidence that
the elderly are particularly susceptible
to periodontal disease, although
confounding variables such as systemic
diseases, reduced manual dexterity, oral
factors and medications have an adverse
effect on periodontal health21 (Figure 6).
Teeth
Age changes in teeth include
physiological wear with superimposed
changes in morphology associated
with pathology, including attrition
and changes in the structure and
composition of the dental hard tissues
(Figure 7).
Enamel
The enamel tends to become
more brittle and susceptible to chipping,
cracking and fracture. It also becomes
less permeable with age, reflecting the
ionic exchange which occurs between
enamel and the oral environment
throughout life. Darkening of the enamel
and staining has also been described
and may be due to absorption of organic
material (Figure 8).
Dentino-pulpal complex
The two main age-related
changes in dentine are continued
formation of secondary dentine,
resulting in reduction in size and in some
cases obliteration of the pulp chamber,
and dentinal sclerosis associated with
the continued production of peritubular
dentine. Both of these processes are also
associated with caries and toothwear.
Dentine sclerosis may affect the use of
adhesive systems with dentine. Sclerosis
of radicular dentine tends to make
the roots brittle and they may fracture
during extraction. It is also associated
with increased translucency of the root.
This starts at the apex in the peripheral
dentine just beneath the cementum
and extends inwards and coronally with
increasing age.
Physiological age changes
are as a result of continued production
of secondary dentine. This reduces the
height of pulp horns, makes the pulp
shrink out of the crown and anterior
teeth, reduces the distance between
chamber roof and floor in posterior
teeth and causes the pulp to narrow
concentrically in roots (Figure 9). The
diminishing pulp space can be further
complicated by the growth of irregular
calcifications around degenerating blood
vessels and nerve cells. These changes
usually comprise spheroid ‘pulp stones’
in the coronal chamber and linear
deposits in the canals.22 Radiographs may
suggest that these changes completely
obliterate the pulp space, but they are
usually interspersed with soft tissue that
provides space and nutrition for microbial
infection, whilst easing the path for
operative disruption and entry (Figure
10).
Pulps undergo physiological
and reactive changes as patients age.
Changes are not, however, uniform and
are not uniquely concentrated in the
chronologically old. Pulp canals in the
elderly are not necessarily narrow and
difficult to manage, and reactive changes
in the young and middle-aged can be
equally challenging.
As the pulp ages, it becomes
Figure 10. Pulp stones in maxillary molar teeth.
October 2010

less vascular, less cellular and more
fibrotic, resulting in a reduced response
to injury and decreased healing potential.
There is also a reduced nerve supply
which, together with a greater thickness
of dentine, makes vitality testing more
difficult. The tissue is tougher and may
not be penetrated as easily with files. The
risk this presents is that entry, even to a
seemingly large pulp, results in compaction
of pulp tissue to form a dense collagenous
plug that is as impregnable as any calcified
deposit. There is special merit in the elderly
of removing pulp tissue with barbed
broaches and the routine use of lubricants
to allow instruments to glide through tissue
rather than compacting it.23
Cementum
Cementum continues to be
formed throughout life, especially in the
apical half of the root, resulting in a gradual
increase in thickness to compensate for
interproximal and occlusal attrition and in
response to trauma, caries and periodontal
disease. The amount of secondary
cementum at the apex of a tooth is a
factor that can be taken into account in
radiographic working length estimation
in endodontics, and in forensic dentistry
in age estimation. Increased amounts of
cementum along with secondary and
reparative dentine diminish tooth sensitivity
and reduce perception to painful stimuli.24
Conclusions
A variety of oral changes may
be observed in elderly patients. These
changes can be attributed to a variety of
physiological and pathological processes
which have developed over a lifetime.
Clinically, it is important to recognize these
changes and to develop planning strategies
which take account of them. Emphasis
must be placed on preventive regimes and
treatment delivery which is sympathetic to
the changing needs of our existing elderly
and ageing population.
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CPD ANSWERS
September 2010
1. A, D 6. A
2. C, D 7. D
3. A, D 8. C, D
4. B, C 9. A, C
5. C 10. C
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