Age Changes in the Oral Cavity (2023-24) - Dr. Casper Jonker - PDF

Age changes in the oral cavity Casper Jonker B.Ch.D, Dip.Odont, MSc, PGCert (ClinEd), AFHEA, MAcadMed, PhD candidate Intended Learning Outcomes By the end of this session the student will be able to: To spiral from earlier consideration of the oral tissues. To review the histological features of the...

Age changes in the oral cavity Casper Jonker B.Ch.D, Dip.Odont, MSc, PGCert (ClinEd), AFHEA, MAcadMed, PhD candidate Intended Learning Outcomes By the end of this session the student will be able to: To spiral from earlier consideration of the oral tissues. To review the histological features of the main dental tissues, enamel, dentine, pulp, cementum, the periodontal complex. To explore the age-related changes which may be observed in each. To discuss how these may impact on decision making in clinical dentistry. Spiralling from earlier teachings Please review earlier teachings on the oral tissues. A number of presentations and resources are posted on the DLE. Some or most of the presentations contain further reading and references. Condensed revision Review of Enamel and Dentine 5-6 minute exercise On a piece of paper, and using your prior knowledge/learning, please write down up to 6 facts each: for Enamel for Dentine Can be based on appearance, structure, function, physicochemical properties, changes during disease, different types etc. Identify the periodontal tissues labelled A-F in this figure. Review of Cementum, PDL and AB 5-6 minute exercise On a piece of paper, and using your prior knowledge/learning, please write down up to 6 facts each: for Alveolar Bone for Cementum For Periodontal ligament Can be based on appearance, structure, function, physicochemical properties, changes during disease, different types etc. Exploring age-related changes General facts Bone Temperomandibular joint (TMJ) Nerves and musculature Oral mucosa Sensory changes Mastication Periodontium Teeth Image: pixabay General facts Globally, there are more than 600 million people over 60 years of age. By 2025 this will most likely be over 2 million people over 80 years in the UK. IMPORTANT CONSIDERATION Changes in their diets whether eating habits, metabolic requirements or a poorly functioning dentition might accelerate the ageing process (Berkovitz, Holland & Moxham, 2017). General facts Poor oral health: increased tooth loss, dental caries, periodontal disease, xerostomia and oral precancer/cancer (Peterson & Yamamoto, 2005). There is a connection between oral and general health. Severe periodontal disease: diabetes mellitus, ischemic heart disease and chronic respiratory disease. Bone Gradual reduction in bone mass. Can lead to osteoporosis (Rochira et al. 2006). Once teeth are lost, atrophy of alveolar bone occur. Image: Mckenna & Burke, 2010 Images: Peninsula Dental School Without dentures, there is a loss of facial height. Upwards and forwards posturing of the mandible. More extensive and quicker in the mandible. Cyclo-oxygenase 2 (COX 2) needed for bone repair reduces: delayed bone healing. Image: Mckenna & Burke, 2010 De Rossi & Slaughter, 2007 Mineralisation of the mandible increases. We as clinicians are aware that tooth extraction can be more challenging! Increase in mineralised bone can be more resistant to bending. Image: clinical case Dr. Casper Jonker Temperomandibular joint (TMJ) Main age changes: related to remodelling of the articular surfaces and disc. In response to functional changes following tooth loss. Remodelling can cause in disc displacement, especially anterior displacement. Image: Dr. Gabriele Baniulyte Temperomandibular joint (TMJ) Retro-discal tissues: adaptive changes due to decreased cellularity and vascularity, and increased density of collagen. Displacement can lead to perforation resulting in joint damage (Soames & Southam, 2005). Image: Dr. Gabriele Baniulyte Nerves and muscles Muscle function is dependent on the performance of the nervous system. 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. Hubbard & Squier, 1989 Peripheral nerve function declines with age. There is a reduction in conduction velocity. Increased latencies in multi-synaptic pathways. Decreased conduction at neuromuscular junctions. Loss of receptors. Advancing age: reduction in total muscle mass. Reduction in the number of muscle fibres rather than a major reduction in muscle fibre size. Particularly over the age of 60: reduction in muscle strength and reduced masticatory force. Lengthening of the chewing process. Elderly patients adapt their chewing behaviour to changes in chewing activity. Oral mucosa Clinically not easy to distinguish from younger patients. However changes over time: Mucosal trauma Mucosal diseases Salivary gland hypofunction * The above can alter the clinical appearance and character. Stratified squamous epithelium becomes thinner. Also loses elasticity and atrophies. Declining immunological responsiveness increasing risk of infection and trauma. Increased incidence of oral and systemic disorders. Increased use of medications may lead to oral mucosal disorders. May develop vesiculobullous, desquamative, ulcerative, lichenoid and infectious lesions Image: Mckenna & Burke, 2010 Oral cancer: primarily a disease of ageing. Associated cell dysregulation. Estimated that more than 90% of all oral cancers in developed countries: older than 50 years. Mean onset during the sixth decade of life. High morbidity. Poor survival rate of less than 50% after 5 years. Sensory changes Taste and smell sensitivities often decline with ageing. Foods become tasteless resulting in a reduction in appetite. Generally, greater difficulty differentiating among food odours. Degeneration of taste buds: reduced taste. Reduction in total number of taste buds (renewal is much slower). Considerable differences in sensory perception. Also to detect the pleasantness of foods change. Ingredients are added (sugars or salt): health effects. Interventions are possible: intensification of the taste and odour of foods. Salivary flow is important for taste perception and intake of food (Muñoz-González et al, 2018). Amplified flavours: more molecules that interact with receptors to compensate for sensory losses. Can increase salivary flow and immunity. Reduce oral complaints in both sick and healthy older patients (Schiffman, 2000). Image: pixabay Salivary glands Dry mouth (xerostomia) and diminished salivary output are common. Approximately 30% of the population 65 years and older experience these disorders. Output from major salivary glands no clinically significant decrements in healthy older people. Most common cause of salivary disorders: prescription and non-prescription medications. 80% of the most commonly prescribed medications can cause xerostomia. More than 400 medications associated with salivary gland dysfunction as an adverse side-effect. Common categories: Tricyclic antidepressants Sedatives and tranquillizers Antihistamines Antihypertensives Cytotoxics Anti-Parkinsonism One treatment for head and neck cancers is external beam radiation. Causes severe and permanent salivary hypofunction. Results is persistent complaints of xerostomia. Within one week of the start of irradiation: salivary output can declined by 60–90%. No recovery unless the total dose to salivary tissues is less than 25 Gy (Turner & Ship, 2007). Most patients receive more than that (60 Gy and more): salivary glands undergo atrophy and become fibrotic. Other causes of salivary gland changes: Sjögren’s syndrome Diabetes mellitus Alzheimer’s disease Dehydration * Sjögren’s syndrome is one of the most frequently encountered chronic autoimmune connective tissue disorders associated with xerostomia. Sjögren’s syndrome: Primary and secondary forms. Primary Sjögren’s syndrome: salivary and lacrimal gland involvement (decreased production). Secondary Sjögren’s syndrome: presents with other autoimmune diseases example rheumatoid arthritis, systemic lupus erythematosis and scleroderma. De Rossi & Slaughter, 2007 Periodontium Prevalence and severity of periodontal disease increases with age. Periodontal changes due to age are not solely responsible for tooth loss especially in a healthy adult. Gingival recession has been considered as an age change. GR is part of the clinical spectrum of periodontitis: plaque is the main aetiological agent. Images: Peninsula Dental School Areas occupied by endoplasmic reticulum (ER) are significantly less. Reduced areas with intracellular collagen profiles. Number and sizes of intercellular contacts are significantly different (decreased numbers; increased size). Aged periodontal fibroblasts: diminished protein synthesis and collagen degradative capabilities. Fat cells start to appear in the older periodontal ligament. Principal collagen fibre bundles become thicker, broader and highly organised. Jagged and uneven alveolar bone with irregular fibre insertions. Teeth might become less mobile: increases in length of the root or changes in the number and diameters of the principal fibres. No evidence that older patients are particularly susceptible to periodontal disease. Variables such as systemic diseases, reduced manual dexterity, oral factors and medications have an adverse effect. Image: Peninsula Dental School Enamel Become more brittle and susceptible to chipping, cracking and fracture. Less permeable with age (reflecting the ionic exchange between enamel and the oral cavity). Image: Peninsula Dental School Both mineral and organic material may be absorbed. Enamel darkening: pigmented or stained organic material included in surface enamel. Also progressive thickening of underlying dentine. Reduced translucency and increased darkening. Surface enamel can become slightly more mineralised. Some ions are exchanged most significantly fluoride from saliva. Possible explanation why enamel has a reduced vulnerability to caries. Bonding of adhesive materials to enamel does not appear to change with age (Berkovitz, Holland & Moxham, 2017). Enamel thickness reduces over time. Both occlusal and interproximal attrition. Severity depends on diet and occlusion. Abrasion and erosion also increase with age. Loss of surface enamel and perikymata disappear. Image: Peninsula Dental School Dentine-pulpal complex Two main age-related: continued formation of secondary dentine. Reduction in size and sometimes obliteration of the pulp chamber. Dentinal sclerosis: continued production of peritubular dentine (intratubular) and associated with caries and tooth wear. Filling of tubules continue and become translucent similar to glass (sclerotic or translucent dentine). Number of tubules in secondary dentine reduce together with the number of odontoblasts. Dentine sclerosis may affect the use of adhesive systems. Sclerosis of radicular dentine: roots brittle and they may fracture on removal. Image: 3M ESPE Increased translucency of the root. Starts at the apex in the peripheral dentine just beneath the cementum. Extends inwards and coronally with increasing age. Physiological age changes: Continued production of secondary dentine. Reduces the height of pulp horns. Pulp move apically out of the crown on anterior teeth. Reduced distance between chamber roof and floor in posterior teeth. Pulp becomes narrow concentrically in roots. Images: Mckenna & Burke, 2010 Growth of irregular calcifications around degenerating blood vessels and nerve cells. Called ‘pulp stones’ in the coronal chamber. Linear deposits in the canals (Goga, Chandler & Oginni, 2008). Radiographs may suggest that these changes completely obliterate the pulp space, but Usually filled with soft tissue, so can be accessible with endodontic instruments. Image: Walton, 2015 Pulp: Between 20 and 70 years, approximately 50% of original odontoblasts is lost. Less vascular, less cellular and more fibrotic. Reduced response to injury. Decreased healing potential. Reduced nerve supply with greater thickness of dentine. Vitality testing more challenging. Pulp: The pulp tissue is tougher: less easily penetrated with endodontic files. This may form a dense collagenous plug that is as impregnable or very difficult to penetrate. Image: Hyflex EDM, Coltene Cementum: Continues to be formed throughout life especially in the apical half of the root. Gradual increase in thickness. Thickness increases roughly threefold between 16 and 70 years. Compensate for interproximal and occlusal attrition, trauma, caries and periodontal disease. Increased small, localised areas of resorption on roots increasing with age. Deposited rhythmically: incremental lines (lines of Salter). Working length estimation in endodontics! Also forensic dentistry in age estimation. Increased amounts of cementum with secondary and reparative dentine: reduce tooth sensitivity and perception to pain. Summary: A variety of oral changes may be observed. Attributed to a variety of physiological and pathological processes over a lifetime. Important to recognise these changes and to develop planning strategies considering them. Preventive regimes and treatment delivery which is sympathetic. References Peterson PE, Yamamoto T. Improving the oral health of older people: the approach of the WHO Global Oral Health Programme. Community Dent Oral Epidemiol 2005; 33: 81–92. Rochira V, Balestrieri A, Madeo B, Zirilli L, Granata ARM, Carini C. Osteoporosis and male age-related hypogonadism: role of sex steroids on bone physiology. Eur J Endocrinol 2006; 154: 175–185. Mckenna G & Burke FM. Age-related oral changes. Dent Update 2010; 37: 519–523. Soames JV, Southam JC. Oral Pathology. Oxford: Oxford University Press, 2005. Hubbard BM, Squier M. The physical aging of the neuromuscular system. In: The Clinical Neurology of Old Age. London: John Wiley and Sons, 1989; 137–142. Schiffman SS. Intensification of sensory properties of foods for the elderly. J Nutr 2000; 130: 927S–930S. Turner MD, Ship JA. Dry mouth and its effects on the oral health of older people. J Am Dent Assoc 2007; 138: 15S–20S. Goga R, Chandler NP, Oginni AO. Pulp stones: a review. Int Endod J 2008; 41: 457–468. Richard E. Walton (2015). Endodontics : principles and practice 1939- author. Fifth edition (also 2021 edition available in library). De Rossi SS, Slaughter YA. Oral changes in older patients: a clinician's guide. Quintessence International. 2007 October; 38(9): 773-780. Muñoz-González, C., Vandenberghe-Descamps, M., Feron, G., Canon, F., Labouré, H., & Sulmont-Rossé, C. (2018). Association between salivary hypofunction and food consumption in the elderlies. A systematic literature review. The Journal of Nutrition, Health & Aging. 2018; 22: 407– 419. Berkovitz, B. K. B., Holland, G. R., & Moxham, B. J. (2017). Oral anatomy, histology and embryology e-book. Elsevier.