The Aging Mouth: Richard H. Moore, PHD

The Aging Mouth
Richard H. Moore, PhD
Medical University of South Carolina/SC-Geriatric Education Center
Objectives
After completing this module, the participant will be able to:
1.
2. 3.
4.
5.
List the changes to the teeth and mouth that most commonly occur with aging Distinguish between normal changes and pathological conditions associated with aging Differentiate between normal and abnormal conditions in the mouths of younger and elderly persons Be able to describe the general processes that are involved in changes in oral tissues associated with the aging process Be able to discuss the normal aging process and how this may be related to disease processes in oral tissues
Supplementary Word Documents

The Glossary, References, Evaluation Form, and Pre-Post Test with Answers for this module are found on a separate MS Word document.
Introduction1
I grow oldI grow old I shall wear the bottoms of my trousers rolled. Shall I part my hair behind? Do I dare to eat a peach?
Opening Activity
Importance Think
of your mouth:
for a moment about how important your mouth is to you and your life. You probably have not done this, but our mouths are important to us in many ways.
Functions of the Mouth

Eating
Speaking Appearance
A Microcosm of the Body

Mouth
contains examples of virtually every type of tissue. Mouth provides numerous examples of how cells and tissues age. Changes do not occur in isolation. Changes result in Normal Aging of the mouth.
Age Changes in Dental Tissues2-5

Change
after their formation are in response to their continued functioning. Allows tissue to continue functioning properly. May lead to a loss of efficiency or use.
Age Changes in Dental Tissues2-5

Dispelling

Myths about Aging:
Tooth loss Diminution in sense of taste Diminution of salivary activity
Most
changes remain within the limits of homeostatic function. Normal activities may not be seriously affected.
Totality of Aging
Changes
the Olympic motto from: "Citius, Altius, Fortius" which is Latin for Swifter, Higher, Stronger
Tardius, Inferius, Fragilius or Slower, Lower, Weaker
To
Changes and Consequences of Aging

Teeth
Gums
/ Jaws Salivary Glands Tongue Taste Swallowing Speech

Teeth6-7
Tooth
Loss Enamel Dentin Pulp Cementum Periodontal Ligament
Tooth Loss8-10
Not
a normal part of aging. A consequence of oral disease:

Caries Periodontal disease Often associated with systemic diseases
Decline in Edentulous Adults8-10

Percent Edentulous Adults*
60
1958
50
Percentage
1962 1975 1986 1997 2000
40 30 20
10
0
18-44
45 -54
55 -64
Age Group
65 -74
75+
Factors Affecting Tooth Loss6,11

The following charts illustrate factors which affect tooth loss:

Education Income Smoking history Race and ethnicity
Relationship of Educational Level and Edentulousness in Elderly Americans

Relationship between Retention of Teeth and Educational Level In Elderly (>64 yrs) Subjects
70
Percentage MIssing 5 or Fewer Teeth
60
50
40
30
20
10
0 < High School High Scool College
Educational Level
Relationship of Retention of Teeth and Annual Income in Elderly Americans

80 70
Percentage Missing 5 or Fewer Teeth
60 50 40 30 20 10 0 <$15,000 $15 -$24,000 $25 -$35,000 $35 -$50,000 > $50,000
Effects of Smoking Upon Retention of Teeth Among Elderly Americans

Effect of Smoking on Retention of Teeth Amoung Elderly ( >64 yrs) Subjects
70 60
50
40
30
20
10
0 Regular Occasional Former Never
Smoker Status
Relationship of Race-Ethnicity and Tooth Loss In Elderly Americans

Relationship between Race /Ethnicity and Tooth Retention Among Elderly (>64 yrs) Subjects
70 60
50
40
30
20
10
0 White (non-Hispanic) Black (non-Hispanic) Multi-racial Race / Ethnicity Hispanic Other
Enamel12
Healthy
teeth go through cycles of demineralization and remineralization throughout life. Aging results in physical loss of tissue through wear and acid erosion, not replaced. Other changes of properties include permeability, mineralization and light transmission.
Dentin
Age Changes:
Increase of volume at the expense of pulp
Increase of secondary and tertiary dentin, more dead tracts and sclerotic dentin found Increase in secondary dentin makes the teeth appear darker
Dentin13-14
Undergoes numerous other alterations associated with caries, aging or induced through treatment or medications.
Demineralization Deproteinization Hypermineralization
Pulp15-17
Reduction
in size with age Fewer blood vessels and nerves Reduced capacity to respond to trauma Reduced immunocompetency
Cementum18
Mineralized
connective tissue Covers roots of teeth Deposition throughout life Deposition increases in response to stress Resulting in increased thickness in some elderly
Periodontal Ligament
Experimental
evidence - width decreases with age but is very responsive to function or decrease of load due to loss of teeth influences width
Increase
Summary of Aging Changes in Teeth
Gums - Jaws
Dentogingival Oral
Junction
Mucosa Skin Bone
External Alveolar
Dentogingival Junction
Longer-in-the-tooth Apical
with age
migration of attachment or periodontal ligament increases with gingival disease
Rate
Oral Mucosa

Epithelium thinner, more fragile, less keratinised Loss of collagen and elastin from fibers also weaken mucosa Increase in pathological change - loss of tongue papillae and taste buds Fordyce's spots increase and minor salivary glands diminish Lesions more common and slower to heal Inflammations, irritation and infections
External Skin
Loss
of fat and water bound mucopolysaccharides - sagging and wrinkling
Fibers
UV
less flexible
light and smoking accelerates aging
Alveolar Bone and Other Connective Tissues19

Loss
of teeth means loss of bone. Loss of alveolar bone leads to loss of vertical dimension. Osteoporosis seen particularly in females after menopause. Effects are exaggerated by malabsorption syndromes.
Salivary Glands
Major
- Minor
Loss of Function Fatty Degeneration and Fibrosis

Changes in Quantity Changes in Composition
Saliva

Salivary Glands

Effects on Taste Effects on Oral Environment Plaque Caries
Apparent Relationship Between Age and the Resting Flow

Rate of Salvia
0.6 0.5
MEN
0.4
0.3
WOMEN
0.2
0.1
0 3544 4554 5564 Age Groups 6569 7074 75+
Age Changes in Salivary Glands20

Volume fraction (Vv; mean SD) of the parenchymal componentsacini and ducts. changes from young to adult group are statistically significant (P < 0.0001).
90 80 70 60 50 40 30 20 12.78 10 0 9.59 4.61 39.55
76.62
56.21
Young Adult Old
Acini
Ducts
Not All Salivary Glands Respond the Same During Aging21

Comparison of Stimulated Salivary Gland Flows in Young (<60) vs. Old (=>60) Individuals
0.9
Parotid Gland
0.8
0.7
0.6
ml/min *
0.5
Submandibular Gland Labial (minor) Glands

Note: flow rate is multipled
0.4
0.3
0.2
0.1
0 Y O Y Age Group O Y O
Changes in Composition of Saliva with Age21

40 35
Na+ 30
Concentration mEq/L or mg/ml
25
Na+ 20 K+ 15 K+
10
Protein APRP
Protein APRP Old (=>60) Age Group
0 Young (<60)
Tongue
Taste Swallowing Speech
and Enunciation
Taste22-27
Greatest
decline in ability to detect salty, bitter and fine tastes slight reductions in the ability to detect sweet and little or no change for sour
Only
Ability
to taste also affected by smoking, dentures and certain medications

Taste27
A
loss of taste is not life-threatening, but it can alter one's eating habits and nutrition.
Loss
of taste buds as an individual ages has been a controversial issue.

studies reveal differing results.
Various
Taste
Recent studies focus on taste stimuli:
Common complaints from medications. Angiotensin-converting enzyme or ACE inhibitors.
Taste28-32
Reasons for decline in sense of taste are unclear or contradictory data:

Possible decline in number of taste buds Possible decline in density of taste buds Possible decline in sensitivity of taste buds Possible decline in neural processing or retrieval All of the above also possible!
Medications Known to Interfere with Taste

Medications, including the most commonly prescribed, interfere with taste or olfactory senses:
Antibiotics: Ampicillin Azithromycin (Zithromax) Ciprofloxacin (Cipro) Clarithromycin (Biaxin) Griseofulvin (Grisactin) Metronidazole (Flagyl) Ofloxacin (Floxin)Tetracycline Anticonvulsants: Carbamazepine (Tegretol) Phenytoin (Dilantin)
Antidepressants: Amitriptyline (Elavil) Clomipramine (Anafranil) Desipramine (Norpramin)Doxepin (Sinequan)Imipramine (Tofranil) Nortriptyline (Pamelor)
Antihistamines and decongestants: Chlorpheniramine Loratadine (Claritin) Pseudoephedrine

Antihypertensives and cardiac medications Acetazolamide (Diamox)Amiloride (Midamor) Betaxolol (Betoptic) Captopril (Capoten) Diltiazem (Cardizem) Enalapril (Vasotec) Hydrochlorothiazide (Esidix) and combinations Nifedipine (Procardia) Nitroglycerin Propranolol (Inderal) Spironolactone (Aldactone)
Anti-inflammatory agents: Auranofin (Ridaura) Colchicine Dexamethasone (Decadron) Gold (Myochrysine) Hydrocortisone Penicillamine (Cuprimine) Antimanic drugs: Lithium Antineoplastics Cisplatin (Platinol) Doxorubicin (Adriamycin) Methotrexate (Rheumatrex) Vincristine (Oncovin)
Antiparkinsonian agents: Levodopa (Larodopa; with carbidopa: Sinemet)
Antipsychotics: Clozapine (Clozaril) Trifluoperazine (Stelazine)

Antithyroid agents: Methimazole (Tapazole) Propylthiouracil Lipid-lowering agents: Fluvastatin (Lescol) Lovastatin (Mevacor) Pravastatin (Pravachol) Muscle relaxants: Baclofen (Lioresal) Dantrolene (Dantrium)
Declines in Taste Perception33
Mean Scores for Three Tastants Mean Scores for Three Tastants Different Aged in Different AgedinGroups33
Groups
3
Mean Pleasantness (>0) / Unpleasantness (<0)
2 1 0 -1 -2 -3 -4 -5 Sucrose Citric Acid Tastant

Young Middle Elderly
NaCl
Swallowing34-37
Reduced
chewing effectiveness Decreased tongue strength
Less muscle and an increase in fatty and connective tissue in the tongue
Atrophy
of the alveolar bone with lost dentition Increased swallowing time with age Swallowing disorders may be prevalent
Speech and Enunciation8-10,38

Speech
is a complex process. Aging changes slowness, deepening of voice Effects of edentulousness & dentures 50% over 85 lack natural dentition Dysphasia and aphasia are results of disease, not aging
Abnormal or Pathologic Aging of the Oral System

Caries Pulpitis
And Periapical Disease Gum Disease Other Microbial Infections Xerostomia

Sialolithiasis (Salivary Duct Stones) Medications Radiation

More Pathologic Conditions

Cancer
Sjgren's
syndrome Burning Mouth TMJ
Caries
Possibly
the oldest known human disease from 12,000 B.C. Affects all human populations, all socioeconomic levels and all ages Decreasing in US youth due to fluoridation and increased dental care Increasing in US elderly due to retention of teeth, root or cemental caries that are difficult to repair
Pulpitis and Periapical Disease39-40

Pulpitis:
An inflammatory reaction in the pulp which can progress to necrosis and focal disease, if untreated Periapical Diseases: A group of inflammatory conditions that involve periapical tissues
Periapical Tissues: Tissues located around tooth apices: periodontal ligament + alveolar bone
Gum Disease
Periodontal
Disease - Red, swollen gums that easily bleed Generally found in older adults Fiber content and blood supply of older gums decline Gums easily damaged, slower to heal
Other Microbial Infections

Oral Candidiasis:
Candidia albicans Thrush Association with dentures Salivary gland dysfunction Other immunocompromising conditions
Xerostomia
Not
a disease, but a symptom Definition:
Decreased saliva production
Saliva

plays vital role in dental health
Re-mineralizes enamel Buffers cariogenic acids Removes food residue Inhibits bacterial growth
Xerostomia - Causes

Not Normal Aging Medications - those with strong anticholinergic effects Tricyclic antidepressants Antispasmodics Neuroleptics MAO inhibitors Antiparkinsonian agents Lithium Central Adrenergic Agonists (antihypertensives) Diuretics Decongestants Antihistamines Bronchodilators
Xerostomia Other Causes

Radiation therapy to head and neck Salivary gland surgery Sjgrens Syndrome Amyloidosis HIV (Human Immunodeficiency Virus) Diabetes Mellitus Major Depression Granulomatous Diseases
Sarcoidosis Tuberculosis Leprosy
Xerostomia - Management
Consider
stopping offending medication Commercial saliva substitute Fluoride supplementation to prevent caries

Use 1.1% Fluoride gel daily Fluoride toothpaste
Scrupulous
dental care is essential
Sialolithiasis - Salivary Duct Stones

May
develop at any age Generally, occur in Whartons duct a submaxillary gland Generally calcareous, may contain uric acid causing gout
Radiation41,42
Primarily
from cancer therapy
Industrial and military occurrences
Taste
loss - nutritional problems Salivary hypo function - xerostomia
Cancer6,12
Most
serious disease associated with aging - 95% occur in people > 40 years Symptoms Five-year survival rate for:

Caucasian Americans - 55% African Americans - 34%
Smoking,
alcohol and sunlight for lip cancers implicated

Sjgren's Syndrome43-45

An autoimmune inflammatory response of the exocrine glands Lymphocytic infiltration of glands results in inflammation and damage Primary vs. Secondary Xerostomia (Sicca) symptoms Can occur at any age, most commonly >45 90% of cases are menopausal women Predisposes patients to dental caries and oral candidiasis Cause unknown
Burning Mouth Syndrome46

A
burning sensation of the oral mucosa without apparent causative lesions Stomatopyrosis or Burning Mouth
Most common in postmenopausal women
Glossopyrosis
or Burning Tongue
Possible symptomatic for other diseases and malnutrition Treatment can be challenging
TMJ Disorders6
Degenerative
alterations not part of
normal aging Articular Non - Articular
Oral Manifestations of Systemic Diseases6,47-48
Evidence of a systemic disease occurring elsewhere in the body is sometimes noted in the mouth. Diabetes Cardiovascular and thromboembolic diseases Preterm Low Birth Weight (PLBW) deliveries Osteoporosis Respiratory Diseases Possible use of pulp stem cells in treating diseases
Diabetes49-51
Increased frequency of tooth loss in diabetics associated with periodontitis Two-way street each represents a risk factor for the other In addition to periodontitis, Type 2 diabetes related to other complications in the oral cavity including tooth decay, dry mouth, fungal infections and oral and peripheral neuropathies
Cardiovascular and Thromboembolic Diseases52-54

Linkage
between periodontal disease and atherosclerosis and thromboembolic events Common basis for inflammatory responses, but cause and effect not established Independent causality? Indication of risk or curative mechanism?
Osteoporosis55
Loss
of alveolar bone associated with osteoporosis Implication of interaction with endocrine system Effects of HRT
Respiratory Diseases56-57
Aspiration
of oral bacteria can result in or exacerbate existing infections Immunocompromised individuals
Dr. Seuss on The Golden Years58

I cannot see I cannot pee I cannot chew I cannot screw Oh, my God, what can I do? My memory shrinks My hearing stinks No sense of smell I look like hell
My mood is bad can you tell? My body's drooping Have trouble pooping The Golden Years have come at last The Golden Years can kiss my ass!
Biography
Richard H. Moore is a Professor in the Department of Biology at Coastal Carolina University in Conway, SC. He received his Ph.D. in Marine Zoology from the University of Texas at Austin in 1973, and since 1974, has been employed at CCU where he currently holds the position of Assistant Vice President for Grants and Sponsored Research. He is an author of Fishes of the Gulf of Mexico: Texas, Louisiana and Adjacent Waters as well as research papers and book chapters in the fields of ecology and physiology. He has taught or currently teaches courses in Human Anatomy and Physiology, Comparative Physiology, Ichthyology, Aquaculture, Vertebrate Zoology and the Biology of Human Aging.

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The Aging Mouth

Richard H. Moore, PhD

Medical University of South Carolina/SC-Geriatric Education Center

Supplementary Word Documents

Medical University of South Carolina/SC-Geriatric Education Center

Medical University of South Carolina/SC-Geriatric Education Center

Medical University of South Carolina/SC-Geriatric Education Center

Functions of the Mouth

Medical University of South Carolina/SC-Geriatric Education Center

A Microcosm of the Body

Age Changes in Dental Tissues2-5

Medical University of South Carolina/SC-Geriatric Education Center

Age Changes in Dental Tissues2-5

Myths about Aging:

Tooth loss Diminution in sense of taste Diminution of salivary activity

Medical University of South Carolina/SC-Geriatric Education Center

Changes and Consequences of Aging

/ Jaws Salivary Glands Tongue Taste Swallowing Speech

Loss Enamel Dentin Pulp Cementum Periodontal Ligament

Medical University of South Carolina/SC-Geriatric Education Center

a normal part of aging. A consequence of oral disease:

Caries Periodontal disease Often associated with systemic diseases

Medical University of South Carolina/SC-Geriatric Education Center

Decline in Edentulous Adults8-10

1962 1975 1986 1997 2000

Medical University of South Carolina/SC-Geriatric Education Center

Factors Affecting Tooth Loss6,11

Education Income Smoking history Race and ethnicity

Medical University of South Carolina/SC-Geriatric Education Center

Relationship of Educational Level and Edentulousness in Elderly Americans

Percentage MIssing 5 or Fewer Teeth

0 < High School High Scool College

Medical University of South Carolina/SC-Geriatric Education Center

Relationship of Retention of Teeth and Annual Income in Elderly Americans

60 50 40 30 20 10 0 <$15,000 $15 -$24,000 $25 -$35,000 $35 -$50,000 > $50,000

Medical University of South Carolina/SC-Geriatric Education Center

Effects of Smoking Upon Retention of Teeth Among Elderly Americans

Percentage Missing 5 or Fewer Teeth

0 Regular Occasional Former Never

Medical University of South Carolina/SC-Geriatric Education Center

Relationship of Race-Ethnicity and Tooth Loss In Elderly Americans

Percentage Missing 5 or Fewer Teeth

0 White (non-Hispanic) Black (non-Hispanic) Multi-racial Race / Ethnicity Hispanic Other

Medical University of South Carolina/SC-Geriatric Education Center

Increase of volume at the expense of pulp

Medical University of South Carolina/SC-Geriatric Education Center

Medical University of South Carolina/SC-Geriatric Education Center

Medical University of South Carolina/SC-Geriatric Education Center

Medical University of South Carolina/SC-Geriatric Education Center

Summary of Aging Changes in Teeth

Medical University of South Carolina/SC-Geriatric Education Center

Mucosa Skin Bone

Medical University of South Carolina/SC-Geriatric Education Center

migration of attachment or periodontal ligament increases with gingival disease

Medical University of South Carolina/SC-Geriatric Education Center

Medical University of South Carolina/SC-Geriatric Education Center

of fat and water bound mucopolysaccharides - sagging and wrinkling

light and smoking accelerates aging

Medical University of South Carolina/SC-Geriatric Education Center

Alveolar Bone and Other Connective Tissues19

Medical University of South Carolina/SC-Geriatric Education Center

Loss of Function Fatty Degeneration and Fibrosis