Aging

Aging

Know how aging affects your body!

Because we are born we must grow old because we grow old, we die this does not mean that all old people are about to die.

It is the duty of the health professional to try to increase the life span and to make later years of the old patient productive and enjoyable.

The care for the dental problems of the elderly citizens must be practiced with increased awareness of the biologic factors.

The elderly are not merely older elderly patient but they require a different approach, modified treatment planning and knowledge of how tissue changes affect oral health services.

The dentist must realize the disorder of aging persons who need not be treated by neuropathy as well as psychotherapy.

The prosthodontist plays a key role in reducing the number of prosthetic feature by a careful understanding of the physical mental and metabolic changes.

The oral changes that occur during aging should be recognized, understand and treated before prosthetic restoration are prescribed for the individuals.

EFFECTS OF AGEING ON ORGAN  SYSTEM

      Aging occurs in each and every organ and tissue of the body. The changes occur to a variable extent in different organs.

The wasted tissue is either not replaced at all or is replaced by a tissue of a defend variety.

Let us see in brief what changes occur in a different organ system.

THE GASTROINTESTINAL SYSTEM

gastric problems

The intestine and the stomach are dilated which is also accompanied by atrophy of the glands causing irregularities in absorption and bowel.

Calcium, iron, Vit. C is not absorbed properly as there is a decrease in the secretion of HCL.

There is also incomplete protein digestion as the secretion of proteolytic enzymes; pepsin, trypsin, and chymotrypsin are markedly reduced.

THE GLANDULAR SYSTEM

There is a marked reduction in the function, metabolism, nutritive enzymatic and hormonal relationship because of progressive atrophy, fibrosis, sclerosis and fatty degeneration of different glands of the body.

THE CARDIOVASCULAR SYSTEM

breathlessness

Blood volume, hemoglobin content of the blood is reduced. Cardiac insufficiency reduces optimal blood supply to tissues result in less oxygen supply to the tissues.

RESPIRATORY SYSTEM

shortness of breath

There is a decreased respiratory efficiency because of gradual lung fibrosis leading to breathlessness after a little physical strain.

MUSCULOSKELETAL SYSTEM

weak bones

There is a loss of elasticity and resiliency in the muscles. The organic matrix of bone is reduced which makes the bone brittle and prone to fractures.

There is a reduction in the osteoblastic activity as a result, there is an apparent increase in the osteoclastic activity which leads to continuous resorption of the bone.

SKIN

aging on skin

The skin of an aging person becomes thin, dry and inelastic. There is atrophy of sebaceous and sweat glands.The subcutaneous fat disappears and hyperkeratotic areas become apparent.

NERVOUS SYSTEM

The cells of this system reach the highest degree of specialization. They die without being able to produce new cells. Aging changes are most evident in such tissues and cells.

NEUROMUSCULAR DISORDERS

Prosthodontist faces severe problems because of an altered capacity of motor learning in elderly patients.

There is diminution of the brain substance.

The ventricular spaces also increase in size causing further reduction in brain substance.

ORAL ASPECTS OF AGEING

      We, as prosthodontists are the caretakers of the human masticatory apparatus and associated structures, need to be familiar with the changes that take place due to aging in the structure and functions of the stomatognathic system.

This does not mean that we should only be concerned with the oral and dental aspects of aging but we should be treating the patient as a whole.

The effects of aging may include:

a)   The oral mucosa and skin changes.

b)   Residual bone and maxillomandibular changes.

c)   Tongue and taste changes.

d)   Salivary flow changes.

e)   Change in the structure of teeth.

  Oral mucous membrane and skin

      The oral mucous of the aging person is friable and can be easily traumatized.

      The aging cells do not enjoy optimal and nourishment. Due to vitamin A deficiency there is reduced cohesiveness and integrity of the epithelial layer. There is a marked reduction in metabolic activity because of vitamin B deficiency and the presence of poorly differentiated connective tissue cells and fibers due to vitamin C deficiency.

The mucosa is thin, tightly stretched and easily blanched.

The atrophying oral mucosa is frequently encountered during menopause.

      There is a reduction of estrogen output which causes the atrophic effect.

For such kind of patients, hormonal replacement therapy is beneficial so as to create a more healthy and favorable environment for the prosthesis.

      Aging also produces changes in the blood vessels. There is a presence of oral varicosities under the tongue and the floor of the mouth.

      The degree of keratinization of the mucosa is of marked significance and must be carefully examined. Because of the lack of keratinization, the protective capacity of the mucosa is reduced and the aging mouth is more prone to suffer from chemical, bacterial and mechanical irritation.

Therefore there is more of irritation in aging patients due to the prosthesis placed in the mouth. The patient should be educated to accept long term adjustment.

      The most dangerous problems associated with epithelial changes in the aging patients arise with the increasing incidence of oral cancers.

75% of the persons in an age group of above 50 years lie in this category indicating a presence of disease in the aging population.

      Similar changes are also seen in the skin.

The skin of the aging person is loose and wrinkled or tight smooth and thin.

As the age increases the skin loses its fine pattern and elasticity. Because of concomitant atrophy occurring beneath the skin, there is a noticeable change in the face.

The muscles, fat and connective tissues all diminish in bulk. Patient management requires to educate them to understand and accept reduced masticatory capacity.

Residual bone and maxillomandibular relation changes

      Bone in the most important tissue for a prosthodontist and implantologist.

If somehow the osteoblastic and the osteoclastic activity are maintained the problem of maintaining dentures would be greatly diminished.

But unfortunately, the osteoblastic activity comes almost to a standstill, therefore, more of resorption is seen due to osteoclastic activity.

      There is a decrease in the anabolic process and increase in catabolic process calcium deficiencies and negative calcium balance are common in aging persons even there is sufficient Ca++ intake the bones lack the ability to retain calcium. As calcium can be retained in the body only if there is enough phosphorus, the later plays a very important role.

      The health of the oral tissues also depends upon proper Ca++ and phosphorus balance.

      If the patient is undergoing radiation therapy there is a decrease in the regeneration powder of bone because of osteoradionecrosis.

      By observing the axial inclination of the teeth, one can predict the direction of bone resorption.

Maxillary teeth generally flare downward and outward so the resorption is upward and inwards. The resorption is faster and greater in the outer cortical plate as the outer cortical bone in maxilla is thin.

      The mandibular residual ridge resorbs lingually and inferiorly in the anterior region and buccally in the posterior region. Since the outer cortex is thicker than the inner cortex except in the posterior teeth region.

Consequently, the maxillary ridge seems to becomes smaller whereas the mandibular ridge in static and or becomes wider in the posterior region.

      There are changes also in the vertical dimension of the maxillomandibular relationship with the passage of time muscle changes occur which are coupled by residual ridge reduction.

As accurate assessment must be made of the prepared interarch and interocclusal distance in elderly persons.

Collagen in the aging bone of the jaw

Collagen is the most abundant protein in man and animals and accounts for about 90% of the non-mineralized content of bone.

There are 11 genetically different types of collagen which have been assigned. Roman numerals by their discoverers.

The one found in the bone in Type I which is a rod-like molecule about 300nm in length and is made from 3 polypeptide chain wound into a triple helix and each molecule contains short non-helical peptide at each end (N-terminus and c-terminus).

In the extracellular matrix, type I collagen assembles into multi-unit structures called fibrils that provide the structural framework of bone.

      The collagen fibers generally increase in stability with aging and this maturation process is related to the content/chemical nature of the cross-links.

ALVEOLAR OSTEOPOROSIS

       Bone loss is a normal part of aging that affects the maxilla and mandible as well as the spine and long bones.

Several factors are thought to contribute to age-related bone loss that leads to osteoporosis: genetic background, hormonal status, bone density at maturity, a disturbance in the bone remodeling process, a low exercise level and inadequate nutrition.

Low calcium intake throughout life is a contributor to osteoporosis.

The physiologic form of the alveolar bone is maintained by a sensitive balance between bone formation and bone resorption, which is regulated mainly by local and to a lesser extent by systemic influences.

Trabecular bone in the alveolar process is a source of calcium that can be used to meet other tissue needs.

The alveolar bone participates in the maintenance of body calcium balance.

Calcium is constantly being deposited and withdrawn from the alveolar bone to provide for the needs of other tissues and to maintain the calcium level of the blood.

Because alveolar bone acts as a reservoir of mineral ions to maintain more vital functions it is susceptible to osteoporosis.

With aging, the bone becomes less dense. Because of this alveolar susceptibility to osteoporosis, some investigators have suggested that internal alveolar resorption may result from dietary calcium deficiency or phosphorus excess, or a combination of both.

Increased bone density has been noted in patients who have been given daily calcium supplements of 1 gm/day for a year.

  Resorption of the alveolar ridge is a widespread problem among denture wearing patients and results in unstable dentures.

In the elderly, there tends to be a relative increase in bone disease and resorption compared with deposition. Some remodeling of the alveolar processes occurs in response to occlusal forces associated with chewing.

With the loss of teeth the alveolar process no longer serves its primary function of tooth support and therefore resorption is accelerated and bone height is diminished.

A greater degree of residual ridge resorption is observed in women than in men.

Bone loss is characterized in the first 6 months after tooth extractions, and resorption is much greater in the mandible than in the maxilla.

The extent of bone loss this way can be so much that the maxillary and mandibular ridges sometimes approach flatness.

This loss in vertical height of bone and the changing of the angle of the mandible is manifested as a loss in face height in older people.

Also, the loss of alveolar bone frequently makes it more difficult to construct a mandibular denture that has good stability and retention.

Dietary calcium is critical to maintaining the body skeleton.

The most important means of preventing metabolic bone disease is acquiring a dense skeleton by the time bone maturation occurs between 30 and 35 years of age.

Calcium intake of postmenopausal women is correlated with mandibular bone mass.

Patients with dentures who have excessive ridge resorption report lower calcium intakes.

A chronically low calcium intake results in a negative calcium balance. For serum calcium levels to be maintained calcium will be mobilized from the bone, and this leads to demineralization of the skeleton.

Although a generous calcium intake by older adults will not result in restoration of bone mass, it will improve calcium balance and slow the rate of bone loss.

Poor vitamin D status is an important public health problem. Adequate intake of vitamin D enhances calcium absorption in the intestine.

Low dietary intake, minimal exposure to sunlight and a lower rate of conversion to the active metabolite in the liver and kidney are responsible for low plasma levels of vitamin D in the elderly population.

To promote bone health postmenopausal women and andropausal men must strive to obtain vitamin D regularly and should increase the intake with advancing age.


MANAGEMENT

taking calcium tablets

Administration of 750 – 1000 mg of calcium and 375 – 400 I.U. of vitamin D daily to patients with low serum calcium or high serum phosphorus or both.

Tongue and taste sensations

      Taste is a major oral sensory system.

The study of taste in aging is complicated by the fact that tasting involves the cooperative functioning of several distinct sensory systems each of which might undergo independent change across the life span.

Taste incorporates input from oral taste receptors along with input from other oral and extraoral sensory systems.

Oral sensory systems include temperature, touch, pain and the sensory-motor mechanisms involved in manipulating substances in the mouth. These systems combine with others to produce subjective impressions of bulk, stickiness, dryness, wetness, and crispness.

      Effects of age upon taste perception might arise from age affects on the anatomy of the taste system.

The taste buds are found in fungiform papillae on the lateral portions of the anterior dorsal tongue, in the circumvallate papillae on the posterior dorsal surface and in the slit-like foliate papillae located on the posterior lateral aspect of the tongue.

The fungiform papillae contain from zero to fifteen taste buds, circumvallate papillae has an average no. in the range of 100-200 and foliate may also contain more than 100 taste buds.

Other taste buds are present their out the oral cavity notably at the junction of the hard and soft palate.

As the aging process takes place there is a change in the number or morphology of taste buds. The tongue is depapillized due to aging. The depapilization begins at the apex and the lateral border.

      It becomes smooth and glossy or red and inflamed in appearance.

The tongue seems to increase in size, there is a loss of muscle tone.

Glossodynia and glossopyrosis are common complaints.

      Vitamin B12 deficiency in menopausal women is characterized by a triad of symptoms:

a)   Generalized weakness.

b)   Sore, painful tongue.

c)   Tingling of the extremities.

The elderly person who live on tea and toast usually suffer from iron deficiency anemia whose oral manifestations are glossitis and fissures at the corners of the mouth.

GLOSSODYNIA AND GLOSSOPYROSIS (PAINFUL AND BURNING TONGUE)

        A painful and burning tongue is often encountered in nutritional anemias associated with deficiencies of vitamin B12, folic acid or iron.

       Vitamin B12 deficiency (pernicious anemia) is seen with increased frequency in older people, especially in women and is characterized by a sore painful tongue and numbness or tingling of the extremities.

The tongue becomes dark red with gradual atrophy of papillae exhibiting a smooth or bald surface.

Not uncommonly in anemic patients, the oral mucosa becomes sensitive and intolerant to dentures.

        Folic acid efficiency like vitaminB12 deficiency causes megaloblastic anemia.

        Elderly patients who live on a tea-and-toast diet are prime candidates for iron deficiency anemia.

However, an adequately nourished older man or postmenopausal woman would probably not have this problem unless there is a hemorrhage.

MANAGEMENT

       Supplement the diet with 5 – 15 mg of folacin tablets daily until reticulocyte count increases. This improvement is maintained with doses of 2 – 5 mg daily.

       Best food sources are yeast, fresh green vegetables, liver, and fruits.

        Ingestion of iron-rich foods such as liver, eggs, and cereals as well as iron supplements like 1 gm of ferrous in 4 divided doses.

  Salivary gland changes

Salivary secretion is usually a reflex response to movement of the jaw during chewing or speaking.

The flow can be increased by aromas of food and stimulation of other special senses and can be reduced due to a variety of causes such as fear, anxiety, deficiency diseases and in alcoholics.

The progressive age-related alterations in major and minor salivary glands include fibrosis, adiposity, and loss of acinar elements.

There is a decrease in the salivary flow the diminished function of salivary glands also results in physicochemical changes.

A decrease in ptyalin content and an increase in mucous content. The saliva is viscous and ropy.

The oral mucosa becomes dry and inelastic resulting in cracking of lips and fissuring of the tongue.

The retention of the denture is also affected. Chewing swallowing becomes difficult because the decrease ptyalin content the digestion of cooked starch is also reduced.

Histological changes in the salivary glands:

There is no doubt that salivary glands undergo histological changes as well.

Depending upon the species and type of gland the salivary parenchyma consists of serous, mucous or mixed acini with various types of ducts arranged in morphological units of lobules.

There is a progressive disparity of size and shape of lobes and lobules.

The ducts also became hyperplastic and dilated with aging.

There is an increase in oncocytes which are prominent features of salivary tumors, the so-called oncocytoma and are associated with a dilator and cystic obstruction of the salivary ducts.

  Changes in the structure of teeth

Like all other oral tissues, the tooth also undergoes change with aging.

There is a loss of calcified tooth structure i.e. enamel leading to sensitivity. There is a recession of pulp in the pulp chamber due to deposition of secondary dentine.

There is also a recession of the marginal gingiva leading to exposure of cementum.

The immune system of the elderly patient is compromised due to aging thus making the patient more susceptible to periodontal disease which subsequently leads to loss of the tooth.

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