Age Changes IN Oral Tissues: Indian Dental Academy

AGE CHANGES
IN
ORAL TISSUES
INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com
Contents
Introduction
Definition
Theories of ageing
Age changes in oral tissues
tissue changes : teeth
periodontium
functional changes :salivary
taste
deglutition
mastication
Prosthodontic considerations
Summary
Conclusion
References
Introduction
Increase in awareness among the medical and
dental practitioners that, older age group
constitute a growing proportion .
An understanding of ageing and the
morphological alterations that occur during
ageing is important to diagnose, plan and treat
the older population.
Definition
Ageing is defined as a process of morphological
and physiological disintegration as distinguished
from infant, childhood and adolescence which are
typified by processes of integration and coordinationCarranza.
A disintegration of the balanced control and
organisation that charecterises the young adult.
General Effects Of Ageing

Tissue desiccation
Decreased elasticity.
Diminished reparative capacity
Altered cell permeability
Ageing leads to limitations in the adaptive capacity

of the organism
Reduced adaptive capacity
Development of age related

pathological
conditionsdeath.
Theories of Ageing
1.
Wear and tear theory
2.
Neuro-endocrine theory
3.
Genetic control theory
4.
Free radical theory
5.
Mitochondrial theory
6.
Waste accumulation theory
7.
Limited number of cell division theory

theories
8. Errors and repairs theory
9. Redundant DNA theory
10. Cross linkage theory
11. Auto immune theory
12. Gene mutation theory
13. Telomerase theory
Wear and tear theory

Given by August Weihmann(1882)
Proposed that organs and tissues were damaged
by continuous use and abuse.
When a person ages, bodys mechanism to repair
the damage caused by wear and tear is reduced.
Hence, in old age people die of diseases which
they could have resisted when they were young.
Neuroendocrine theory
Given by Vladimir Dilman.
In neuroendocrine system, a complicated network
of biochemicals governs release of hormones.
Hormones in turn work together to regulate body
functions.
Ageing causes drop in hormone production.
Hormone production is interactive i.e, one
hormone level falls leading to the fall in others.
Decline in ability of the body to repair itself.
Free radical theory

Introduced by R.Gerschman,1954
Free radical is a molecule that has one free
electron
Free radical activity is required to produce energy,
maintain immunity, nerve transmission.
But free radicals also attack cell membranes
producing metabolic waste products
LIPOFUSCHINS.
Lipofuschins interfere with the ability of the cells
to repair and reproduce themselves.
The telomerase theory of ageing recent.

Monumental progress in ageing research,but
there is yet to be a unanimous decision on which
theory holds good.
Age related changes do not occur uniformly in
individuals, but they are under the influence of
genetic and environmental factors.
Age changes in oral tissues

Tissue changes
Functional changes
1. Teeth
1. Salivary
2. Periodontium
2. Taste
-bone
3. Deglutition
-periodontal ligament
4. Mastication
-oral mucous
membrane
Changes in Tissues
Age changes in teeth

Regressive alterations
Attrition
Abrasion
Erosion
Enamel
Dentin
Cementum
Pulp
Attrition
Physiologic wearing
away of tooth as a
result of tooth to tooth
contact.
Causes-masticatory stress
-para-functional
habits
Common in males
Stages of Attrition
1. Stage I
Wear of enamel of cusps and incisal edges without
exposure of dentin.
2. Stage II
Wear of enamel and exposure of dentin on incisal edges
and isolated area over individual cusps.
3. Stage III
Wear of enamel forming a broad strip on incisal edges
and
the confluence of two are more areas of wear
over
adjacent cusps.
4. Stage IV
Wear of enamel and dentin on incisors to form a plateau
and on the teeth to form a central area of dentin
surrounded by a peripheral rim of enamel.
Abrasion
It is the pathological
wearing away of tooth
through abnormal
mechanical processes.
e.g.- abrasive
dentifrice
- occupational
- improper flossing
Dentifrice abrasion
Toothpick abrasion
Bobby pin abrasion

Erosion
Loss of tooth
substance by a
chemical process that
does not involve
known bacterial
action.
Lingual erosion
e.g. -chronic vomiting

-acidic carbonated
beverages
Labial erosion
Age changes in Enamel

Macroscopic
-becomes darker
-attrition, abrasion, erosion
-longitudinal cracks
Microscopic
- decreased - enamel rod ends
- perikymata
- permeability to fluids
- increase in nitrogen and fluorine
Increased resistance to decay
Age changes in Dentin

Dentin is laid down through out life.
Dentin laid down after birth is Secondary Dentin.
Pathologic effect of dental caries, abrasion,
attrition or other operative procedures cause
variable changes in dentin
- Reparative Dentin
- Dead Tract
- Sclerotic Dentin
Reparative Dentin
Also called as Irregular Dentin/ Tertiary Dentin/
Irritation Dentin
. Localised close to the irritated zone of the tooth.
Clinically : decreased sensitivity in tooth.
incidence in anteriors is higher
Bevelender and Benzer*
Histopathologically : dentinal tubules lesser in

number, irregular, tortuous
Radiologically : decreased size of pulp chambers

and root canals
* J.Am.Dent.Assoc., 1943
How does Reparative Dentin form?

insult/injury to the tooth
odontoblasts
Degenerate
form repararive dentin

Seals off the zone of injury
Initiating healing process
In pulp
Dead Tracts
Empty tubules filled with air, where ododntoblsts
have degenerated.
In ground sections, they entrap air ,so appear
black in transmitted light and white in reflected
light.
Decreased sensitivity in these areas.
Probably the initial step to form sclerotic dentin.
Dead Tracts - ground section
Dead tracts
Sclerotic Dentin
Protective changes in response to any injury in
primary dentin itself.
Collagen fibrils and apatite crystals apppear in
dentinal tubules.
Therefore their lumen is obliterated.
With the obliteration of dentinal tubules, the
refractive indices of the dentin are
equalised.thus called TRANSPARENT DENTIN.
Transparent in transmitted light and dark in
reflected light. www.indiandentalacademy.com
Sclerotic dentin under a zone of

caries
Carious lesion
Sclerotic dentin
pulp
Age changes in Dental Pulp

1. Reduction in size
and volume of
pulp :
Reduction in pulpal
area in coronal pulp
because of continual
apposition of dentin
occlusally and in
furcation area
Young tooth
Reparative dentin
Old tooth
Decrease in size
of pulp
2. Reduction in cell number :

-fewer cells with reduced number of organelles
like RER, mitochondria, etc.
-odontoblasts, fibroblasts degenerate.
3. Changes in collageneous elements :
-increase in collagen fibers.
-von Korffs fibers are accentuated.
-pulpal fibrosis in old teeth is not because of
continual formation of collagen fibers ,instead it
can be attributed to persistance of connective
tissue sheath..
Shrof , Stanley and Ranney
#
# Oral Surg. 1953

* Oral Surg. 1962
4. Changes in blood vessels :

-narrowing of circumference of vessels.
-atherosclerotic changes in small arteries.
-intimal layer of the vessel is thickened which
results in a small lumen.
5.Changes in nerve distribution :

-nerves aggregating at the core appear prominent.
-degeneration and loss of pulpal nerve fibers
affects transmission from pulpal structures and
results in increase in threshold for pain stimulus.
-axonal and perineural changes are also seen.
- Myelin sheath changes and terminal axon
remolding due to age related axon injury could be
sources of abnormal pain in the oral region.
6.Pulp calcifications :
- Calcified masses appearing in coronal and root
portions of pulp.
- seen in functional as well as embedded teeth.
- two types
1. Pulp Stones/Denticles
2. Difuse
calcifications.
-histologically
-does not resemble
similar to dentin.
dentin.
-common in coronal
-common in root pulp.
pulp.
-amorphous unorganised
columns paralleling
blood vessels and nerves
Based on histolological
appearance
True pulp stones
False pulp stones
Resemble
secondary dentin
Dont exhibit dentinal
Fewer tubules
Irregular tubules
tubules
Usually larger than
true denticles
Based on location, pulp

calcifications are
Attached pulp stone
Free pulp stone
Amorphous calcifications
around blood vessels
Pulp chamber
dentin
Diffuse calcifications
Age changes in Cementum

Thickness of cementum is one of the criteria to
assess age of an individual.
Increase in thickness at the root by 5 to 10 times
with age.
Greater apically and lingually and in the
bifurcation in molars.
Permeability decreases with age.
Hypercementosis
It is the abnormal thickening
of cementum.
Occlusal stress
Spike like projections formed
Increase surface area for
Periodontal ligament
attachment
Age changes in Bone

Adapts to meet the functional demands.
Histologically there is decrease in bone forming
cells.
Blood capillary walls supplying the bone, thickened
with age..in old age, bone derives its nutrition
mainly from periosteal blood supply.
Increased resorption which is not balanced by
adequate formation of bone.
Increase in the porosity of bone
Atkinson and
Hallsworth*.
* Gerodontology 1983
Osteoporosis
It is a disorder that adversely affects the collagen
metabolism with concomitant decrease in bone
mass.
May be due to negative calcium balance.
Common in females.
Reduces the bone mineral content of jaws and
associated with periodontal attachment loss and
tooth loss.
One of the reason for increased residual ridge
resorption.
Residual ridge resorption

With age, number of teeth present in the oral
cavity decreases.. so the force acting on the
remaining teeth is more.
The changes in the alveolar processes of
edentulous persons are more marked.
In the first year after tooth extraction reduction
of height in the mid sagittal plane is about 2 to 3
mm for maxilla and 4 to 5 mm for mandible .
Decrease in vertical dimension at occlusion.
Decrease in lower facial height
Annual rate of reduction in height is 0.1 to 0.2mm

and in general four times less in edentulous
maxilla.
Etiology : anatomic factors
-short square face related to elevated
masticatory forces
-alveoloplasty
prosthodontic factors
-intensive denture wearing
-unstable occlusal conditions
metabolic and systemic factors
-osteoporosis
-calcium and vitamin D supplements
Changes in Maxilla
- Maxillary teeth are directed downward and
outward thus bone reduction is upward and
inward.
- Resorption on outer cortex is greater and more
rapid because outer cortical plate is thinner than
the inner cortical plate
- Thus the maxilla becomes smaller in all
dimensions and the denture bearing area (basal
seat) decreases.
Maxillary bone resorbs

on the crest and labial
and buccal cortices.
Thus, maxillary ridge
loses height and
becomes narrower in
transverse and antero
posterior direction.
Resorption towards
centre
Changes in Mandible
- The mandibular ridge resorbs primarily on the
crest of the ridge.
- Because the mandible is wider at its inferior
border than at the residual alveolar ridge in the
posterior part of the mouth, resorption, in effect,
moves the opposite sides of the ridges farther
apart.
Mental foramen :
With the resorption of the alveolar process the
mental foramen lies at or near the level of the
upper border of ridge.
Genial tubercles :
. The genial tubercles project above the upper
border of the mandible in the symphyseal region.
The residual alveolar

ridge becomes wider
with resorption.
Resorption away from
centre.
- Density of mandibular bone decreases from 1.9 to

1.5% between 45 and 90yrs,value being 8% less
in females
Henrikson and Wallenius*
- Lamina dura is often lost and cortical bone at

angle of mandible becomes thinner
*
J. oral Rehabil. 1, 1974
# Gerodontics 1, 1985
Sharpio et al#
Age changes in mandible
At
adulthood
In childhood
birth
old age
Age changes in periodontal

ligament
Increase in number of fibroblasts.
Greater collagen and elastic fibre content.
Decrease in organic matrix production.
Width of periodontal space increases with occlusal
loading.
Age may be a probable risk factor for periodontitis.
Periodontitis
It reflects the age related change and
accumulation of previous dental experiences.
Gingival recession
Loss of periodontal attachment and alveolar
bone.
Age Changes in Oral Mucous

Membrane
Surface of oral cavity is mucous membrane and
its structure varies in apparent adaptation to
function
Clinically :
-dry
-friable
-thin smooth mucosal surfaces
-loss of elasticity and stippling.
-predisposed to trauma and
infection.
According to Massler- tissue friability arises from

three sources
1. A shift in water balance from the intracellular to
the extracellular compartment and diminished
kidney function results in dehydration of the oral
mucosa.
2. Progressive thinning of the epithelial layers
which increases tissue vulnerability to mild
stress.
3. Nutritionally deficient cell.
Histologically : -thinning of epithelium
-loss of cohesiveness of epithelial cells

vitamin A deficiency
-decreased prominence of retepegs
-loss of submucosal elastin and fat
-increased fibrous connective tissue
-degenerative alteration of collagenvitamin C deficiency
Result in a mucosa which is more prone for
traumatic injuries and delayed wound healing.
Migration of Junctional Epithelium

Migration of junctional epithelium from its normal
position to a position more apical gingival
recession.
Occlusal plane
Original gingival margin location

Original cementoenamel junction
Mucogingival junction
Changes in Function
Salivary glands
Appear less compact with ducts occupying major
portion.
Increased focal adenitis.
Rate of production of secretory proteins is
decreased by slowing secretory activity of the
gland.
In normal, healthy, non medicated individuals
secretion does not change.
Composition does change Na+ lower
-
Baum et al*
Cl _,protein lower Chauncey et al
* Adv. Physiol. Sci., 1981

# Am. J. Physiol., 1984
Xerostomia
Dryness of mouth.
Is usually not seen in healthy non medicated
individuals.
Associated with persons on medications like
diuretics
tranquilizers
anti histaminics
Also seen in patients with sjogrens syndrome.
Xerostomia causes
dryness of the
mucosa.
Fissured tongue
Fissured tongue.
Angular chelitis.
Angular chelitis
Tongue and Taste sensation

Number of taste buds decline with age.
At 70yrs, taste buds decrease to 1/6th of those
present at the age of 20yrs.
Acuity of taste sensation is decreased because:
- of depapillisation,which usually begins at
apex and lateral regions
- of hyperkeratinisation of epithelium
- of degeneration of nerves gradually.
One of the common age change is nodular

varicose enlargement of veins on ventral surface
of the tongue (caviar tongue).
Threshold for sweet and acid are not affected by
ageing, but salt and bitter are
* J Gerodontology, 1982
Weifenbach et al*.
Mastication and deglutition

1. Most frequent oral motor disturbance in older
persons is related to mastication

2. Masticatory ability is further decreased in those
who are partially or fully edentulous.

3. Biting force is said to be decreased by 16% of its
original value in older patient.

4. Ultrasound imaging has estimated the oral and
pharyngeal phases of swallowing to be longer in

older than younger
adults
The biting force reduces from 300lb/in2 to 50lb/in2

with age Kaplan .
*
Lip seal is less efficient in older subjects
Baum and
Bodner#.
Swallowing time is increased by 25 to 50% in

subjects over age of 55years sonies et al .
^
* Geriatrics, 1971
# J dent Res. 1983
^ Gerodontology, 1984
Prosthodontic
considerations
Thin friable epithelium may not be able to

tolerate the forces imposed on it by the hard
unyielding acrylic denture base.
Hence, such areas must be relieved.
Improper impression techniques may distort the
tissues.
Compression of the tissues during denture
wearing leads to denture sore mouth.
Lammie (1960) postulated the theory of epithelial

atrophy results in decrease in number of
epithelial cells, thus decreasing the surface area.
This in turn applies pressure onto the residual
ridge.
Xerostomia affects the denture retention .
Sore spots are seen under the denture as there is
lack of lubrication.
Residual ridge resorption is centripetal in maxilla

and centrifugal in mandible making maxilla
comparatively narrower and mandible broader.
The surface of the arches maybe resorbed out of
parallelism which can result in diminished
stability of dentures.
Severe ridge resorption can also result in
increased inter arch space.
In cases of severe attrition and abrasion, there is

loss of vertical dimension..results in aged
appearance.
Prosthodontic reconstruction restablishes vertical
dimension and lip support,gives esthetic
appearance.
Summary
Age changes in oral tissues can be broadly
classified into TISSUE and FUNCTIONAL changes.
Tissue teeth
- periodontium
Functional taste
- salivation
- mastication
- deglutition
Various alterations in mouth due to ageing have
various prosthodontic implications.
Conclusion
A thorough understanding of the morphological
alterations that occur during ageing is important,
for, such knowledge will help in understanding of
the functional changes that may lead to
decreased activity and in assessing the health of
the subjects and identify reasons for departures
from the normal.
References
1. Boucher ( 2004)Prosthodontic Treatment for
Edentulous Patients 12 edition . Mosby
2. Sheldon Winkler(2004) Essentials of complete
denture prosthodontics :second edition
3. Sharry J.J. Complete denture prosthodontics
1962
4. Age changes and the Complete Lower Denture
J Prosth Dent 1956;6:(4)450
5. Ferguson D B ( 1987 )The Aging Mouth Vol 6
Karger,Basel
6. Burket (2003) Oral Medicine 10 edition B C Decker
7. Shafer (1999) A Textbook of Oral Pathology 4

edition W B Saunder.
8. Geriatric Dentistry The Dental Clinics Of North
America ; 89;33:1 Clinical decision making in
Geriatric Dentistry The Dental Clinics Of North
America: 1997:41:4
9. V.V Frolkis(1984) Physiology of cell ageing: Vol 18
karger
10. Lavaelle(1988) Applied Oral physiology: second
edition; Wright
11. Langlais and Miller: Color Atlas of common oral
diseases; third edition: Wolters Kluwer
12. Orbans Oral Histology and Embryology(1990),

tenth edition.
13. Stopping the clock(1997),Dr.Donald Klatz and
Dr.Robert Goldman
Youth is a gift of nature,

but age is the work of art.
Thank you
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AGE CHANGES

General Effects Of Ageing

Ageing leads to limitations in the adaptive capacity

Reduced adaptive capacity

Development of age related

Wear and tear theory

Genetic control theory

Free radical theory

Waste accumulation theory

Limited number of cell division theory

Wear and tear theory

Free radical theory

The telomerase theory of ageing recent.

Age changes in oral tissues

Age changes in teeth

Bobby pin abrasion

e.g. -chronic vomiting

Age changes in Enamel

Age changes in Dentin

Histopathologically : dentinal tubules lesser in

Radiologically : decreased size of pulp chambers

How does Reparative Dentin form?

form repararive dentin

Dead Tracts - ground section

Sclerotic dentin under a zone of

Age changes in Dental Pulp

2. Reduction in cell number :

# Oral Surg. 1953

4. Changes in blood vessels :

5.Changes in nerve distribution :

False pulp stones

Dont exhibit dentinal

Based on location, pulp

Attached pulp stone

Free pulp stone

Age changes in Cementum

Age changes in Bone

Residual ridge resorption

Annual rate of reduction in height is 0.1 to 0.2mm

Maxillary bone resorbs

The residual alveolar

- Density of mandibular bone decreases from 1.9 to

Henrikson and Wallenius*

- Lamina dura is often lost and cortical bone at

J. oral Rehabil. 1, 1974

Age changes in mandible

Age changes in periodontal

Age Changes in Oral Mucous

According to Massler- tissue friability arises from

Histologically : -thinning of epithelium

-loss of cohesiveness of epithelial cells

traumatic injuries and delayed wound healing.

Migration of Junctional Epithelium

Original gingival margin location

Cl _,protein lower Chauncey et al

* Adv. Physiol. Sci., 1981

Tongue and Taste sensation

One of the common age change is nodular

Mastication and deglutition

persons is related to mastication

who are partially or fully edentulous.

original value in older patient.