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 population in 65 years and older experience these disorders and their accompanying oral and pharyngeal consequences.
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 anadverse side-effect.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 anti cholinergic effects are 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 preturb ion transport pathways in the acinar cell, may adversely affect the quality and quantity of salivary output.Common categories of these drugs include;
-Tricyclic antidepressants
-Sedatives and tranquillizers
-Antihistamines
-Antihypertensives
-Cytotoxics; and
-Anti-Parkinsonism drugs
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.
Numerous systemic medical conditions, including :
-Sjogren's syndrome
-Diabetes mellitus
-Alzheimer's disease: and
-Dehydration
can cause or contribute to salivary gland diseases.Sjogren's syndrome is one of the most frequently encountered chronic autoimmune connective tissue disorders and is the most common systemic condition associated with xerostomia.Sjogren's syndrome occurs in primary and secondary forms.Those patients with primary have salivary and lacrimal gland involvement, with an associated decreased production of saliva and tears.In secondary form, the disorder presents with other autoimmune diseases, such as rheumatoid arthritis,systemic lupus erythematosis and scleroderma.
Periodontium
Epidemiological studies show that the prevalence and severity of periodontal disease increases with age.This is most likely the result of repeated episodes of active destruction occuring over time rather than an intinsic change associated with 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 a part of the clinical spectrum of periodontitis in which plaque is the main aetiological agent.There is no evidence that the elderly are particularly susceptible to periodontal disease,although confounding variables such as systemic disease, reduced manual dexterity, oral factors and medications have an adverse effect on periodontal health.
Teeth
Age changes in teeth include physiological wear with superimposed changes in morphology associated with pathology, including attrition and changes in the structure of composition of the dental hard tissue.
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.
Dentino-Pulpal Complex: 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 tooth wear.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 increased age.
Physiological 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.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. Radiographs may suggest that these changes complitely 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.
Pulps undergo physilogical and reactive changes as patients age.Changes are not, howeer,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 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 routine use of lubricants to allow instruments to glide through tissue rather than compacting it.
Cementum: Cementum continues to be formed throughout life, especially in the apical half of the root,resulting in a gradual increase ith the thickness to compensate for interproximal and occlusal attriton 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 in to account in radiographic working length estimation in endodontics,and in forensic dentistry in age estimation.Increase amounts of cementum along with secondary and reparative dentine diminish tooth sensitivity and reduce perception to painful stimuli.
Conclusions
A variety of oral changes may be observed in elderly patients.These changes can be attributed to 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 changing needs of our existing elderly and ageing population
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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 population in 65 years and older experience these disorders and their accompanying oral and pharyngeal consequences.
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 anadverse side-effect.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 anti cholinergic effects are 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 preturb ion transport pathways in the acinar cell, may adversely affect the quality and quantity of salivary output.Common categories of these drugs include;
-Tricyclic antidepressants
-Sedatives and tranquillizers
-Antihistamines
-Antihypertensives
-Cytotoxics; and
-Anti-Parkinsonism drugs
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.
Numerous systemic medical conditions, including :
-Sjogren's syndrome
-Diabetes mellitus
-Alzheimer's disease: and
-Dehydration
can cause or contribute to salivary gland diseases.Sjogren's syndrome is one of the most frequently encountered chronic autoimmune connective tissue disorders and is the most common systemic condition associated with xerostomia.Sjogren's syndrome occurs in primary and secondary forms.Those patients with primary have salivary and lacrimal gland involvement, with an associated decreased production of saliva and tears.In secondary form, the disorder presents with other autoimmune diseases, such as rheumatoid arthritis,systemic lupus erythematosis and scleroderma.
Periodontium
Epidemiological studies show that the prevalence and severity of periodontal disease increases with age.This is most likely the result of repeated episodes of active destruction occuring over time rather than an intinsic change associated with 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 a part of the clinical spectrum of periodontitis in which plaque is the main aetiological agent.There is no evidence that the elderly are particularly susceptible to periodontal disease,although confounding variables such as systemic disease, reduced manual dexterity, oral factors and medications have an adverse effect on periodontal health.
Teeth
Age changes in teeth include physiological wear with superimposed changes in morphology associated with pathology, including attrition and changes in the structure of composition of the dental hard tissue.
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.
Dentino-Pulpal Complex: 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 tooth wear.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 increased age.
Physiological 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.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. Radiographs may suggest that these changes complitely 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.
Pulps undergo physilogical and reactive changes as patients age.Changes are not, howeer,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 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 routine use of lubricants to allow instruments to glide through tissue rather than compacting it.
Cementum: Cementum continues to be formed throughout life, especially in the apical half of the root,resulting in a gradual increase ith the thickness to compensate for interproximal and occlusal attriton 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 in to account in radiographic working length estimation in endodontics,and in forensic dentistry in age estimation.Increase amounts of cementum along with secondary and reparative dentine diminish tooth sensitivity and reduce perception to painful stimuli.
Conclusions
A variety of oral changes may be observed in elderly patients.These changes can be attributed to 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 changing needs of our existing elderly and ageing population
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