Oleh :Drg Maharani L.A, Sp PM

Eating

Speaking

Appearance

Oral cavityGums / JawsSalivary GlandsTongueTasteSwallowingSpeech

Tooth Loss EnamelDentinPulpCementumPeriodontal Ligament

Not a normal part of aging.A consequence of oral disease:CariesPeriodontal diseaseOften associated with systemic diseases

The following charts illustrate factors which affect tooth loss:EducationIncomeSmoking historyRace and ethnicity

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.

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

Undergoes numerous other alterations associated with caries, aging or induced through treatment or medications.

DemineralizationDeproteinization Hypermineralization

Reduction in size with ageFewer blood vessels and nervesReduced capacity to respond to traumaReduced immunocompetency

Mineralized connective tissueCovers roots of teethDeposition throughout lifeDeposition increases in response to stressResulting in increased thickness in some elderly

Experimental evidence - width decreases with age but is very responsive to function

Increase or decrease of load due to loss of teeth influences width

Dentogingival Junction

Oral Mucosa

External Skin

Alveolar Bone

Longer-in-the-tooth with age

Apical migration of attachment or periodontal ligament

Rate increases with gingival disease

Epithelium thinner, more fragile, less keratinisedLoss of collagen and elastin from fibers also weaken mucosaIncrease in pathological change - loss of tongue papillae and taste budsFordyce's spots increase and minor salivary glands diminishLesions more common and slower to healInflammations, irritation and infections

Loss of fat and water bound mucopolysaccharides - sagging and wrinkling

Fibers less flexible UV light and smoking accelerates aging

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.

Major - Minor Loss of Function Fatty Degeneration and FibrosisSalivaChanges in QuantityChanges in Composition

Effects on TasteEffects on Oral Environment Plaque Caries

Taste

Swallowing

Speech and Enunciation

Greatest decline in ability to detect salty, bitter and fine tastes

Only slight reductions in the ability to detect sweet and little or no change for sour

Ability to taste also affected by smoking, dentures and certain medications

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.

Various studies reveal differing results.

Recent studies focus on taste stimuli:

Common complaints from medications.

Angiotensin-converting enzyme or ACE inhibitors.

Reasons for decline in sense of taste are unclear or contradictory data: Possible decline in number of taste budsPossible decline in density of taste budsPossible decline in sensitivity of taste budsPossible decline in neural processing or retrievalAll of the above also possible!

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)

Speech is a complex process.Aging changes slowness, deepening of voiceEffects of edentulousness & dentures 50% over 85 lack natural dentitionDysphasia and aphasia are results of disease, not aging

CariesPulpitis And Periapical DiseaseGum DiseaseOther Microbial InfectionsXerostomiaSialolithiasis (Salivary Duct Stones)MedicationsRadiation

CancerSjgren's syndrome Burning MouthTMJ

Possibly the oldest known human disease from 12,000 B.C.Affects all human populations, all socioeconomic levels and all agesDecreasing 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: An inflammatory reaction in the pulp which can progress to necrosis and focal disease, if untreatedPeriapical Diseases: A group of inflammatory conditions that involve periapical tissuesPeriapical Tissues: Tissues located around tooth apices: periodontal ligament + alveolar bone

Periodontal Disease - Red, swollen gums that easily bleedGenerally found in older adultsFiber content and blood supply of older gums declineGums easily damaged, slower to heal

Oral Candidiasis:Candidia albicansThrushAssociation with denturesSalivary gland dysfunctionOther immunocompromising conditions

Not a disease, but a symptomDefinition: Decreased saliva productionSaliva plays vital role in dental healthRe-mineralizes enamel Buffers cariogenic acids Removes food residue Inhibits bacterial growth

Not Normal AgingMedications - those with strong anticholinergic effectsTricyclic antidepressants Antispasmodics Neuroleptics MAO inhibitors Antiparkinsonian agentsLithium Central Adrenergic Agonists (antihypertensives) Diuretics Decongestants Antihistamines Bronchodilators

Radiation therapy to head and neck Salivary gland surgery Sjgrens SyndromeAmyloidosisHIV (Human Immunodeficiency Virus)Diabetes MellitusMajor DepressionGranulomatous DiseasesSarcoidosisTuberculosisLeprosy

Consider stopping offending medication Commercial saliva substitute Fluoride supplementation to prevent cariesUse 1.1% Fluoride gel daily Fluoride toothpaste Scrupulous dental care is essential

May develop at any ageGenerally, occur in Whartons duct a submaxillary glandGenerally calcareous, may contain uric acid causing gout

Primarily from cancer therapyIndustrial and military occurrencesTaste loss - nutritional problemsSalivary hypo function - xerostomia

Most serious disease associated with aging - 95% occur in people > 40 yearsSymptomsFive-year survival rate for: Caucasian Americans - 55% African Americans - 34% Smoking, alcohol and sunlight for lip cancers implicated

An autoimmune inflammatory response of the exocrine glandsLymphocytic infiltration of glands results in inflammation and damagePrimary vs. SecondaryXerostomia (Sicca) symptomsCan occur at any age, most commonly >45 90% of cases are menopausal womenPredisposes patients to dental caries and oral candidiasisCause unknown

A burning sensation of the oral mucosa without apparent causative lesionsStomatopyrosis or Burning MouthMost common in postmenopausal womenGlossopyrosis or Burning TonguePossible symptomatic for other diseases and malnutritionTreatment can be challenging

Degenerative alterations not part of normal agingArticularNon - Articular

Evidence of a systemic disease occurring elsewhere in the body is sometimes noted in the mouth.DiabetesCardiovascular and thromboembolic diseasesPreterm Low Birth Weight (PLBW) deliveriesOsteoporosisRespiratory DiseasesPossible use of pulp stem cells in treating diseases

Increased frequency of tooth loss in diabetics associated with periodontitisTwo-way street each represents a risk factor for the otherIn 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

Linkage between periodontal disease and atherosclerosis and thromboembolic eventsCommon basis for inflammatory responses, but cause and effect not establishedIndependent causality?Indication of risk or curative mechanism?

Loss of alveolar bone associated with osteoporosisImplication of interaction with endocrine systemEffects of HRT

Aspiration of oral bacteria can result in or exacerbate existing infectionsImmunocompromised individuals

*Eating: The mouth, teeth and tongue are important in ingesting and preparing food for digestion and assimilation.Speaking: The teeth, tongue and the other parts of the mouth are used to make the proper sounds. They help us speak clearly. Appearance: The mouth is used when we smile or make other expressions. The teeth help give shape and form to our face. They help us look good to ourselves and others. Eating is vital for health and nutrition, but dinner time is important in many other ways. Most special events like family reunions, weddings, anniversaries, birthdays or that hot date next Friday night, religious events such as Christmas, Easter, Passover and even national holidays like Thanksgiving and the Fourth of July, are all associated with meals. These serve as social occasions in which conversation as much as the opportunity to acquire nutrients plays an important role. How we look or think we look and how we feel about ourselves will affect our participation. Psychological, social, economic and cosmetic factors all interact with our health to either create a beneficial experience or one that detracts from the quality of life. So, our mouths play a vital and central role in maintaining our overall physical and mental health throughout our lifetime. Changes that occur in and to our mouths as we age, present us with the challenge of maintaining healthy or successful aging criteria into our elder years.

*Age changes and their consequences are observed in many tissues of the mouth and in the functions which they normally provide. This module provides a summary of some of these changes, as well as changes that may be associated with pathological conditions that might be expected in the elderly.*TEETH:Tissues in our mouth change as we grow older. Tooth enamel can be eroded and dissolved by the action of acids from foods or produced by microbes in the mouth. Once the protective enamel is gone, the interior of the teeth can be attacked. The resulting infection will lead to tooth decay and eventual loss. The remaining teeth may become darkened and more brittle. Soft tissues lose their ability to stretch and to heal. The amount of saliva produced by glands in your mouth is frequently reduced resulting in dry mouth conditions that affect our ability to taste and also speeds up the processes of tooth decay. With age, teeth become less white and more brittle. Oral hygiene habits and use of tobacco, coffee and tea also have profound effects on tooth color. Teeth also can darken or yellow due to the thickening of the underlying dentin. Brittle teeth tend to be susceptible to cracks, fractures and shearing.6

Over a lifetime, the enamel layer is subjected to wear due to chewing, grinding and ingestion of acidic foods. In severe cases, the enamel may be completely worn away and the underlying dentin attacked by acidic oral fluids, leaving teeth with only a fragile, brittle, enamel shell. These teeth are easily chipped or broken. Inside the tooth pulp, the number of blood vessels and cells decrease and fibroses increase with age. Thus, the capacity to respond to trauma may also decrease. Teeth undergoing inherent aging changes are symptom-less, whereas teeth subjected to trauma are often painful.7 *Tooth loss is not part of the normal aging process, but is a consequence of oraldisease. Aging does not cause oral diseases, but oral diseases, including tooth loss, are more common with age. This is partly due to older persons having been alive longer and consequently, having had a longer time for the effects of poor oral hygiene to accumulate. Partly, this is due to changes that are normally associated with aging such as:

Changes in the soft tissues that surround the teeth,A depression of the immune system, An increase in the number of systemic diseases, Decreased ability in older persons to perform adequate oral hygiene and self care as a result of age-related diseases, such as stroke, arthritis, Parkinson's disease, dementia, or Alzheimer's disease and Dry mouth due to greater use of prescription and over-the-counter medications. Edentulousness is on decline in US.8-10 See the following chart.

*The US Department of Health and Human Services-NIH 2000 Report entitled: Oral Health in America: A Report of the Surgeon General, discusses some of the factors aside from age that affect tooth loss. Among these are education, income level, smoking history, race and ethnicity.6 Charts on the following four slides illustrate and summarize these data. In these slides, tooth retention means individuals loosing five or fewer of their natural teeth with wisdom teeth excluded. *ENAMEL:Enamel is the hardest substance in the body a translucent layer of highly ordered hydroxyapatite, a mineral made up of calcium phosphate. It is 90% mineralized. Throughout life, tooth enamel goes through cycles of demineralization and remineralization. But, if it is destroyed, it is not replaced. As we age, enamel undergoes several changes. These changes include thickness, permeability, mineralization and light transmission which affects the color of the enamel. Normal enamel is translucent. The underlying dentin is white to yellowish. Light passing through the enamel is reflected by the dentin, giving your teeth their color.12Enamel thins with age due to a lifetime of wear and tear as well as acidic erosion from acid foods or acidic bacterial metabolites. Even excessive horizontal tooth brushing can result in abrasion of the enamel. As noted, enamel is normally translucent, but may take on color from smoking, food like blueberries, beverages especially red wine, tea and coffee or medications like tetracycline that are adsorbed on the surface. Despite these changes, enamel in older people continues to absorb fluoride or remineralization, making continued use of fluoride toothpastes or fluoride treatments an important part of dental hygiene-care.12*DENTIN:Dentin is softer than enamel, but still harder than bone. It consists mainly of apatite crystals of calcium and phosphate, which is only about 70% mineralization and contains proportionally more collagen fibers and cells. Dentin is produced by the odontoblasts, cells that line the pulp cavity of the tooth. Dentin is a living tissue which has the ability for constant growth, repair and reacts to physiologic or functional and pathologic or disease stimuli. Primary dentin is formed during tooth formation. Once a tooth becomes functional, subsequent formation of dentin results in secondary dentin, somewhat less mineralized and with more irregular tubules than the primary dentin. Tertiary or reparative dentin forms in response to injury: dental abrasion, attrition, cavity preparation, erosion or dental caries. Tertiary dentin appears to have less structural organization and strength than the original dentin which it replaces. Although the exact form and the regularity of tertiary dentin appears to be dependent on the intensity of the external stimulus. Hypercalcification of dentin tubules can also occur in response to injury and is referred to as sclerotic dentin. The amount of sclerotic dentin increases with age, proceeding from the root apex towards the crown. There are also obvious optical changes in the tissue, which becomes translucent, while normal dentin is normally opaque. *Age changes in dentin include: increase of thickness and volume at the expense of pulp, decline in number and density of odontoblasts and other cell types with decreases in the root being greater than those in the crown region, an increase of secondary and tertiary dentine, more dead tracts and sclerotic dentin found. Aging teeth develop secondary dentin over time that also makes the teeth appear darker.13-14

*PULP:Pulp is a loose connective tissue containing cells, ground substance, collagenous fibers, nerves and blood vessels that is encased in solid, bonelike wall of dentin and cementum. Pulp contains a variety of cells, chiefly odontoblasts that produce the fibers and ground substance of the tissue, histiocytes that produce macrophages and Mesenchymal cells that differentiate to produce the other cell types.15 Pulp also includes a variety of immunocompetent cells, especially Class II major histocapability complex (MHG) expressing cells and macrophages.1Mast cell lymphocytes, plasma cells and eosinophils typically occur only near sites of inflammation. With aging, pulp cavity is reduced by deposition of secondary dentin and could conceivably be obliterated. The pulp gradually becomes smaller with fewer blood vessels and less nerve tissue supplying the teeth. As a result, teeth have less fluid content and become brittle and may be easily broken or chipped. The number of blood vessels and cells in the pulp decrease and fibroses. Often the remnant connective tissue sheaths of degenerated nerves and blood vessels increase with age. Thus, capacity to respond to trauma may also decrease. Odontoblasts degenerate beginning near the root apex and advancing towards the crown. The density and composition of those pupal cells expressing macrophage-associated antigens becomes more variable with aging. Collagen fibers form cross-links, darken and produce toxic substances via the Maillard reaction such as lipid peroxidases that interfere with structural and functional properties of other molecules.

*CEMENTUM:Dental cementum is a mineralized tissue, closely resembling bone, that covers the roots of teeth and serves to anchor gingival and periodontal fibers. Some types of cementum may also form on the surface of the enamel of the crown. Both bone and cementum are composed of approximately 65% inorganic components and about 35% organic components, with relatively few cells per volume/mass of mature tissue. Cells embedded within the cementum are cementocytes, which are formed by cementoblasts found in the periodontal ligament. The organic matrix that forms the basic structural component of cementum is, like that of bone, composed of collagen fibers. Unlike bone, cementum is not vascular and exhibits little turnover. Cementum grows slowly throughout life by surface apposition. Deposition appears to occur in response to functional stress. In older animals, as in elderly humans, cementum may make up a greater proportion of the tooth. The cementum layer widens first in apical region. In functional teeth, this may help compensate for loss of enamel around the gum line, although impacted teeth in the elderly also show increased width of the cementum layer.18

*PERIODONTAL LIGAMENT:The periodontal ligament is the fibrous connective tissue structure, with neural and vascular components, that binds the cementum covering the root to the alveolar bone. The periodontal ligament serves primarily a supportive function by attaching the tooth to the surrounding alveolar bone by means of numerous collagenous fibers. In this respect, it can be likened to a hammock that cushions as well as supports the tooth. The periodontal ligament also serves a major remodeling function by providing cells that are able to form as well as resorb all the tissues that play a role in tooth attachment, such as bone, cementum and the periodontal ligament Undifferentiated ectomesenchymal cells, located around blood vessels, can differentiate into the specialized cells that form bone or osteoblasts, cementum or cementoblasts, as well as connective tissue fibers or fibroblasts. Bone-and tooth-resorbing cells such as osteoclasts and odontoclasts are generally multinucleated cells derived from blood-borne macrophages. The periodontal ligament is richly supplied with nerve endings that are primarily receptors for pain and pressure and so also serves a sensory function. Finally, through its circulatory component, the periodontal ligament provides a nutritive function that maintains the vitality of its various cells.Little is known about age-related changes to the periodontal ligament in adults outside of the obvious effects of tooth loss and periodontal disease. While these may require long periods to develop, they are not associated with normal aging. Other aging-related factors, such as tissue fragility and slow healing, may also play important roles. It has been suggested that its width decreases with age, but as the ligament is very responsive to function any increase or decrease of load due to loss of teeth will influence its width.*Summary of Aging-Changes in Teeth:All of these changes can occur in teeth and many are reducible or preventable with proper dental care. Cusps become worn from abrasion. Enamel can become thinned and pitted by erosion and wear. Caries can occur in reduced enamel layer. Infections may spread into the interior of the tooth, leaving enamel unsupported. Inside the tooth, the dentin layer enlarges and the pulp is reduced. More tertiary and sclerotic dentin can occur. Reduction in pulp results in reduced nutritive, reparative and immunological functions. The gumline recedes forming pockets and exposing roots. Root caries occur in exposed the cementum. Periodontal ligament retreats apically.*GUMS AND JAWS:Our mouth and the gums go through many changes as we age. The majority of people over 50 have been affected by some form of gum or periodontal disease and tooth-root decay. Many cavities occur around the edges of old fillings. Brushing with a fluoride toothpaste, flossing, following a healthy, nutritious diet and regular dental visits remain important.

*We get longer-in-the-tooth with age, the result of receding gums and the apical migration of the periodontal ligamentary attachment. The rates of gum recession and ligamentary recession increase with gingival disease.

*ORAL MUCOSA:Age-related changes in the oral mucosa are similar to those in skin. Epithelium becomes thinner and more fragile due to a loss of keratin. Loss of collagen fibers also weakens mucosa. Increase in pathological change results in loss of tongue papillae and taste buds. Fordyce's spots or ectopic sebaceous glands increase and minor salivary glands diminish. Soft tissue lesions are more common in older adults and tooth loss may occur. Chronic inflammation such as candidiasis or fungus growth and denture irritation also occur more often. Wound healing is decreased due to reduced vascularity or blood flow to the area and immune response with age. In edentulous persons, changes in the mucosa are exacerbated by the presence of removable dental prostheses. *EXTERNAL SKIN:Loss of fat and water bound mucopolysaccharides results in increased sagging and wrinkling. Due to loss of collagen, elastin and collagen cross-linking fibers become less flexible. Exposure to UV light or smoking accelerates aging. Although most of these changes are primarily cosmetic, they can affect a persons well being and attitude towards dental care.*ALVEOLAR BONE:Osteoporosis and periodontitis are two diseases commonly associated with aging. Systemic osteoporosis includes loss of bone density in the bones that support the teeth. Osteoporosis is a risk factor for periodontitis. Anatomically, alveolar bone is the bone of the maxilla and mandible that contains the alveoli for the teeth. It provides support and protection for the teeth. The following concept is important: the alveolar bone is dependent on the functional forces exerted upon the teeth to maintain its structure. When the teeth are lost, the alveolar bone, in time, will be lost also. This alveolar bone presents a special challenge to the dentist when making a denture for geriatric patients who have been edentulous for many years.19

*SALIVARY GLANDS: Major-Minor: Change in numbers, mass and activity.Saliva: Changes in chemical composition, physical properties resulting in effects on taste and effects on environment such as more plaque and cavities. Until the 1990s, it was generally believed that salivary production decreased with age. But, earlier studies did not appreciate that other factors, such as medications and smoking history, will result in decreased salivary flow independent of age. More recent studies have produced conflicting results. While some appear to show declines, others appear to show no declines but have increases in salivary flow with age. Many studies, recent as well as older ones, are flawed by small sample sizes. Sometimes these are with fewer than 10 subjects or restricted range of ages. One study included no individuals over 49; another had none under 73; yet, both purported to investigate effects of aging on salivary activity.

*In both major and minor salary glands, there are anatomical changes that occur with aging. The number of acinar cells that produce saliva atrophy or decrease with age. The remaining tissues of the glands show an increase in fatty tissue and fibroses. However, healthy, unmedicated older adults do not have reduced saliva flow. This is because the salivary glands have a high reserve capacity. Usually when a decrease in saliva flow is noted, it is associated with medication use, illness, medical conditions or treatment of a disease.The composition of saliva also changes. For example, one of the following charts shows a decline in sodium levels. Declines in some the concentrations of kallikrein, sIgA, low-molecular mucin and high-molecular mucin have also been reported. This could reflect decreases in the capacity of the oral cavity to fight off infections.Increased lipid peroxide or free radicals levels in both oral tissues and saliva may contribute to plaque development and tooth erosion. Plaque is a biofilm a structured organization of microbial cells, both motile and sessile in a matrix of water, organic and inorganic materials. Saliva both sustains and flights plaque. It is a medium for transport of bacteria within and between mouths, but it also helps prevent cell reattachment or agglutigens, kills or antimicrobial and flushes bacteria and dietary material from the tooth surface.

*TONGUE:The tongue is involved in taste, swallowing, speech and enunciation. All these functions may change with age.*TASTE:A reduction of taste is not usually life-threatening, but it can alter one's eating habits. It is generally agreed that older adults show reduced taste discrimination ability, but the cause for this decline in function is not well understood. Ability to taste is also affected by nutrition, smoking, dentures, diseases, oral hygiene and certain medications. According to the Merck Manual of Geriatrics, the sense of smell and fine taste starts to diminish gradually when persons are in their 50s, because of neural degeneration. Smoking may accelerate the process. Since the ability to taste is closely related to smell, taste perception may be altered in older adults. Loss of fine taste does not appear to be related to loss of lingual taste or deficits in cognition. Like olfactory function, taste perception is reduced with normal aging. Compared with younger persons, the elderly tend to perceive tastes as being less intense. The fact that many seniors take medicine regularly may compound the problem. For example, Schiffman, 1997, found that elderly people who take an average of three medications require two to 15 times more of a taste to experience it as vividly as do younger people.22-27*The issue of whether or not taste buds are lost as an individual ages has been controversial. Early studies based on cadavers, suggested that the number of taste buds on circumvalate and foliate papillae declined with age. More recent studies on living subjects have failed to reveal a similar change in taste buds on fungiform papillae and have reported greater variations in numbers of taste buds among healthy, young individuals than what were considered as age-related declines in the earlier studies. As an example, Miller, 1988, showed over a 100-fold difference between individuals in taste bud density spread evenly among age groups and sexes. Results from studies performed on non-human mammals have largely conformed to these conclusions as well. However, much of the research on age-related chemoreceptive change has been based on studies with small sample sizes, inappropriate age ranges, inadequate psychophysical and stimuli presentation procedures and poor dietary intake assessment, which leave findings inconclusive. While most recent medical textbooks have taken the position that there are no age-related declines in numbers of taste buds, many other texts and information resources for health care professionals, care givers and the general public continue to repeat, uncritically, the assertion that taste bud numbers decline with age.The exact cause of these declines is not known. Many early studies concentrated on trying to determine whether there are aging changes in the number, size or density of taste buds. The results of most of these studies are now viewed as inconclusive. Like a majority of recent authors, Hayflick feels that the reduced ability is not due to a reduction in number of taste buds, but rather to a reduction in the number of sensory cells within the bud and degeneration within the cells. Whatever the cause, abilities to detect salt and bitter decline with age more than sweet and sour, but even for the latter the elderly do not perceive these with as much pleasure. Men are more prone to losses than women.27*Most recent studies have focused on the ability to perceive taste stimuli. Either the subjects judgment of taste quality and strength or the biochemical events leading to the electrochemical transmission of sensory data to the brain. While aging effects are found in the ability to perceive taste stimuli as well as in the pleasantness-unpleasantness of such stimuli, in many cases the levels of sensitivity are well below those levels normally encountered in foods and should therefore, have little effect on the ability of the elderly to discern tastes in real life.However, conditions independent of aging, such as smoking, dentures, oral hygiene, disease and certain medications can more seriously affect the elderlys ability to perceive taste and can in turn have a greater effect on that persons well being. Besides affecting nutrition, older people are more prone to food poisoning since warning signals provided by chemosensory abilities may have declined.According to Schiffman, taste change effects are among the more common complaints for many medications, and these impairments can not only affect a patient's quality of life but can interfere with patient compliance. Angiotensin-converting enzyme or ACE inhibitors, notably captopril or Capoten, are among the medications most commonly associated with taste disturbances, including decreased sense of taste, hypogeusia, and a strongly metallic, bitter or sweet taste. Adverse side effects can especially impact patient compliance for antihypertensive medications, in which the disease itself may be symptomless, but treatment can be lifelong. In addition, taste disturbances in the elderly can lead to decreased food intake and weight loss -- and ultimately poor health outcomes -- in a population already at risk for nutritional deficiencies.

*TASTE:A survey of resources on the Internet through a Google search for taste bud numbers and aging revealed 114 discrete sites of which only eight contained information indicating that there was no change in taste bud number or that the results of studies were equivocal. The remaining sites, including some hosted by the National Institute of Aging,( NIH) several medical schools, state health extension agencies and textbooks for nursing students, dental hygienists and geriatric social workers repeated the assertion that taste bud number declines, usually without citing any source for this claim.A smaller number of taste buds could explain why the elderly are only capable of recognizing the flavors of certain foods. The density rather than absolute number of taste buds, however, could provide an even better explanation of the observed. Researchers have speculated about whether or not a person's taste bud density changes as he or she ages, causing gradual changes in the ability to recognize certain flavors of foods. Miller,29 found in one of his studies, that taste bud density does not really diminish with age, but rather it stays at an equal level based on the person's individual health. In this case, a person's health could influence taste sensitivity.During the course of a lifetime, taste buds are constantly renewed on approximately a 10-day cycle. It has been suggested that with aging, less vigorous replacement of taste cells may reduce loss of perception in elderly.Receptor cells found in taste buds are known to degenerate when they lose their connections to the brain, so aging changes in the Central Nervous System (CNS) could not only affect the ability to interpret taste sensations, but the capacity to receive these in the first place.Whatever the cause, the elderly have a less specified taste acuity than the young, for which the noise hypothesis provides an explanation, either at a neural level, at a psychological level, or at both levels. However, an explanation in terms of physiological aging cannot be excluded. Although it seems that renewal and redundancy in the taste system preserve gustatory function in old age, it is not clear that the functioning of aged taste buds is not impaired.28-32

*Several hundred medications including many of the most commonly prescribed, are known to interfere with taste or olfactory senses.

****Speech and Enunciation:Speech is a complex process involving visual and auditory input, central processing and motor output, not only to the vocal muscles but also to the facial muscles. The facial muscles produce expression and are thus, an integral part of vocal communication. Speech patterns change with age. The voice becomes deeper and may develop an increasing tremor, speech becomes slower and may develop an abnormal prosody. Enunciation of consonants becomes imprecise.38Close to 50% of Americans age 85 and over have no natural teeth. There are unique problems associated with the edentulous state. Functionally, the teeth aid in mastication and enunciation, however, ill fitting dentures can interfere with speech patterns, and the removal of dentures can aid in speech.8-10Changes in pronunciation and enunciation are quite common in the aged. Dysphasia and aphasia are less common. Dysphasia is difficulty in speaking or in understanding language. Aphasia is loss or impairment of the capacity to use words as symbol of ideas. Both are caused by brain lesions, often a consequence of stroke, and not by changes in the mouth.

*A variety of pathological conditions can affect the oral cavity. While none of these are caused by aging nor are they unique to the elderly, some are more common among the elderly. They present particular difficulties in diagnosis and treatment among the elderly.*The following slides illustrate and discuss these conditions.*Caries:Dental caries have afflicted humans longer than any other disease. While it was not prominent in the earliest humans, dental caries appeared around 12,000 B.C. or about 14,000 years ago. From that time to the present, dental caries have afflicted almost all human populations, all socioeconomic levels and all ages.The disease starts in young people just as soon as teeth erupt. About 90% of youngsters are affected by age 14. The incidence of caries is decreasing in this young population in the US and in other Western countries. This downward trend is explained by increased fluoridation of water supplies and by increased attention to regular care at dental offices and at home.Despite recent reductions in the overall occurrence of dental caries, the rate of tooth decay may still increase with age. This is especially true when the amount of saliva is reduced. Tooth decay in older adults appears most frequently around or below the gum line. In this population, gingival recession exposes root surfaces to oral fluids which has led to an increase in cemental caries. If plaque is allowed to form on the exposed root surfaces, bacterial invasion of cementum will occur. Microorganisms will inhabit holes left by the detachment of periodontal ligament fibers or Sharpeys fibers. Because cementum is deposited concentrically around the root, bacterial invasion tends to follow a concentric pattern. As a consequence, cemental caries proceeds on a very broad front. Repair of cemental caries is technically demanding and often unsuccessful. Prevention of plaque deposition in older people and prevention of cemental caries is a better approach to this difficult aging problem.*Pulpitis and Periapical Disease:Bacterial infections caused by dental caries are the most common cause of pulpal disease. But, there are also ways bacteria can infect the pulp in the absence of dental caries. Having cracked teeth is one example. It is not uncommon for teeth, particularly restored teeth in the elderly, to have a hairline crack extending through the crown traversing the pulp chamber. If that occurs, bacteria in saliva enter the dental pulp through the crack. It is conceivable, but rare, for a bacteria in an infection elsewhere, like the kidney, to be carried by blood to the dental pulp. The reverse of this, an infected tooth causing infections elsewhere, was once thought by physicians to be a common source of systemic infections known as focal infections.39Bacteria associated with dental caries can invade adjacent bone. In progression, dental caries invades enamel or cementum, dentin and pulp. When dentin is invaded, bacteria gain access to the pulp. Upon entering the pulp, an inflammatory reaction results that, in fully-formed teeth, causes pulpal death. From the pulp, bacteria enter the surrounding bone through the apical foramen. The ensuing inflammatory response of the tissues surrounding the apical foramina is periapical disease or apical periodontitis.40*Gum Disease:Periodontal disease can be described as red or swollen gums that bleed with the slightest irritation. Pockets often develop between teeth and gums and can pack or trap food. This disease is generally found in varying degrees in older adults. If not treated, the disease becomes more and more destructive. In the elderly, periodontal disease is a primary cause for tooth loss.The fiber content and number of blood vessels of the periodontal or gum tissues decrease with age. However, periodontal disease represents a pathologic or disease change and is not due to just age. The loss of bone and gum attachment or receded gums associated with periodontal disease is collective and therefore, greater in older adults. An outcome of periodontal disease is exposed root surfaces. Exposure of the root in older people probably gave rise to the term "long in tooth. Oral hygiene practices and certain medications affect the health of gum tissue. Receded gums and exposed root surfaces put older adults at high risk for dental decay or caries on the relatively soft root surfaces. Dental caries on root surfaces is a disease that is common among older adults. Dry mouth and a diet high in sugars and fermentable carbohydrates greatly increase the risk for root caries. Dental caries are a major cause of tooth loss in older adults.*Other Microbial Infections:While not a disease restricted to the elderly, oral candidiasis is not uncommon among elderly patients. Oral candidiasis refers to infection of the oral cavity caused by Candida species, commonly C. albicans. Oral candidiasis, a common infection among the elderly, has several forms. Acute pseudomembranous candidiasis or thrush is characterized by leukoplakic plaques that appear as white patches and that can be scraped away to expose an erythematous base; hyperplastic candidiasis, by confluent leukoplakic plaques that cannot be scraped away; angular cheilitis, by leukoplakic and erosive lesions at the lip commissures; and atrophic candidiasis, by painful erythematous mucosal lesions, frequently located beneath dentures.Oral candiditosis is often associated with dentures. The long-term use or over use of antibiotics will also often result in candital infections. Treatment with topical and/or systemic antifungal drugs is required, and any infected dentures must be treated separately and kept out of the mouth for extended periods.Risk factors include salivary gland dysfunction, certain drugs such as antibiotics, antineoplastics, corticosteroids, immunosuppressants, diabetes mellitus and other immunocompromising conditions. The presence of candidal hyphae in oral smears indicates that the oral mucosal barrier has been breached and that the patient is at risk of systemic infection.

*Xerostomia:Not a disease, but a symptomDefinition: Decreased saliva production Saliva plays vital role in dental health:Re-mineralizes enamel Buffers cariogenic acids Removes food residue Inhibits bacterial growth *XEROSTOMIA - Causes:Although declines in salivary function were once regarded as part of normal aging, it is now thought that they are not. Instead, a leading cause of xerostomia, especially among the elderly is medications with anticholinergic effects. In general, the stronger the anticholinergic effects, the greater the xerostomia. Physicians may be advised to prescribe alternative medications with lesser effects.

*None are unique, but some are more common in the elderly, creating a predisposition to xerostoma. Some of these causes are discussed separately elsewhere in this module.*XEROSTOMIA MANAGEMENT:Management of xerostomia can be fairly straight forward:Consider stopping offending medication and replace with alternative will lessen anticholinergic effect.Commercial saliva substitute. Fluoride supplementation to prevent caries Use 1.1% Fluoride gel daily Fluoride toothpaste Scrupulous dental care is essential to prevent caries and periodontal disease.

*SIALOLITHIASIS Salivary Duct Stones:Patients of any age may develop salivary duct stones. The vast majority of such stones occur in Wharton's duct from the submaxillary gland. The patient will be alarmed by the rapid swelling beneath his jaw that suddenly appears while he is eating. The swelling may be painful but is not hot or red and usually subsides within two hours. This swelling may only be intermittent and may not occur with every meal. Infection can occur and will be accompanied by increased pain, exquisite tenderness, erythema and fever. Under these circumstances, pus can sometimes be expressed from the opening of the duct when the gland is pressed open. Salivary duct stones are generally composed of calcium carbonate and calcium phosphate. Uric acid stones may form in patients with gout. Although the majority form in Wharton's duct in the floor of the mouth, approximately 10% occur in Stensen's duct in the cheek and 5% in the sublingual ducts. Depending on the location and the size of the stone, the presenting symptoms will vary. As a rule, the onset of swelling will be sudden and associated with salivation during a meal.

*RADIATION:Humans can receive dosages of radiation from several sources. Today, although industrial accidents and military events may result in exposure, the majority of radiation exposures come from cancer therapy. As such, they should be controlled and the after effects anticipated. Patients who receive radiation therapy for head and neck cancer often experience taste loss, which can lead to compromised nutritional intake as described elsewhere in this module.Following radiation therapy, especially in combination with chemotherapy, salivary gland function drops off quickly. Patients who have low saliva production develop dry mouth or xerostomia, increasing the risk of developing caries and periodontal disease as well as interfering further with the sense of taste. The severity of dry mouth depends on how much of the salivary gland is radiated. Short-term recovery is possible after mild radiation, but high dosages or long-term exposure leads to irreversible loss of salivary function. Drugs or radio-protectors and the latest, lower energy, radiation treatments may reduce these undesirable effects.41,42

*CANCER:Oral and oropharyngeal cancer is the most serious disease associated with age. Oral and oropharyngeal cancer lesions usually are not painful. Disease may appear as a red or white patch, a sore or ulceration or a lump or bump that does not heal within two weeks. Swollen lymph nodes of the neck, result in difficulty swallowing and speaking. Voice changes may also be signs and symptoms of oral and oropharyngeal cancer. The risk for oral and oral pharyngeal cancer increases with age, use of all forms of tobacco, frequent alcohol use and exposure to sunlight for lip cancer. Squamous cell carcinoma accounts for 96% of oral and oropharyngeal malignancies. Of the 28,000 new cases of oral cancer reported in the United States annually, more than 95% occur in people ages 40 or older. Age is the primary risk factor identified in epidemiologic analyses. The five-year survival rate for Caucasian Americans is approximately 55% and for African Americans, 34%. Carcinoma of the lip, tongue and floor of mouth represent over 65% of all oropharyngeal cases. Lip cancer affects men eight times more frequently than women. Most other sites affect men at a ratio slightly below 2:1. Oral cancer is strongly linked with the use of tobacco, particularly cigarettes. Lip cancer has a strong correlation with pipe and cigar smoking.6,12*SJOGRENS SYNDROME:An autoimmune inflammatory response of the exocrine glands in which the salivary and lacrimal glands become infiltrated with lymphocytes that produce inflammatory cytokines for example, interleukin-2, -interferon. Salivary gland duct cells also produce cytokines, eventually damaging the secretory ducts.43,44Primary Sjgren's syndrome occurs when dry eyes and mouth are not associated with a rheumatic condition. Secondary Sjgren's syndrome is associated with rheumatic conditions or connective tissue disease such as lupus, scleroderma or polymyositis. Xerostomia and dry eyes or Sicca symptoms are among the most common symptoms. It can affect many other organs and systems including joints, muscles and nerves, organs such as the lungs, kidneys, liver, pancreas, stomach and brain or glands such as the thyroid gland and potentially, can cause complete destruction of any of these areas. It can occur at any age, but usually occurs after age 45. Ninety percent of cases are women and is often associated with menopause. It predisposes patients to dental caries and oral candidiasis.45 The cause is not known, but genetic and environmental factors such as Epstein-Barr, Hepatitis C and other viral infections may be implicated. *BURNING MOUTH SYNDROME: Stomatopyrosis and Glossopyrosis:Burning sensation of the oral mucosa without apparent causative lesions. Stomatopyrosis, commonly called burning mouth syndrome, is a poorly understood painful chronic disorder of the mouth, which is most common among postmenopausal women. Glossopyrosis, burning tongue, is a common form of stomatopyrosis. Proposed causes include: ill-fitting dentures; nutritional deficiencies of vitamin B1, B2, B6, or B12 or folic acid; local trauma; gastrointestinal disorders; allergies; salivary hypofunction and diabetes.Burning sensations may be constant, gradually increasing throughout the day or intermittent without any reliable alleviating agents. Diagnosis of stomatopyrosis is the one exclusion. If oral lesions are present, the diagnosis is not stomatopyrosis. For example, patients with oral candidiasis may have a burning sensation in the mouth, but they do not have stomatopyrosis. Because stomatopyrosis and glossopyrosis are often idiopathic, treatment can be challenging and frustrating. Referral to a specialist in chronic pain syndromes should be considered. Antidepressants such as nortriptyline or clonazepam, given in low doses at bedtime are beneficial. Spontaneous remissions are not uncommon, but exacerbations may occur.46*TMJ DISORDERS:TMJ undergoes degenerative alterations and are not part of normal aging. Two types of pathologies articular related to joint itself and non-articular (occurring in structures related to the joint and encasing similar or referred symptomatology. Examples of the latter include: trigeminal neuralgia, dental pulpitis and otitis.6*ORAL MANIFESTATIONS OF SYSTEMIC DISEASE:Evidence of systemic disease in the body is sometimes noted in the mouth.6 Periodontitis has been traditionally regarded as a chronic inflammatory oral infection. However, recent studies indicate that this oral disease may have profound effects on systemic health, particularly cardiovascular disease, diabetes, tissue repair capacity and immune cell function. Additional evidence links periodontal disease with the occurrence of pre-term, low birth weight babies.47Finally, although not a linkage between dental health and systemic diseases, it has been suggested that dental pulp may serve as a good source of stem cells in treatment of Parkinsons and other neurodegenerative diseases and spinal cord injuries.48 *DIABETES:The increased frequency of tooth loss in diabetics has been associated with periodontitis, accompanying tooth mobility and deep pocket formation. Diabetes has been implicated in the development of significant periodontal disease and with other significant local effects on the oral cavity that contribute to periodontal disease.49It has been demonstrated that diabetes was a risk factor for periodontal disease, but it is becoming apparent that periodontal disease is a risk factor for diabetes.50 Those people who don't have their diabetes under control are especially at risk. Cutler et al.,1999, found that periodontal disease is more likely to develop in patients with poorly-controlled type 2 diabetes than in well-controlled diabetics. Their research also suggests that periodontal disease may make it more difficult for people who have diabetes to control their blood sugar. Severe periodontal disease can increase blood sugar and contribute to increased periods of time when the body functions with a high blood sugar. This puts diabetics at increased risk for diabetic complications. Thus, diabetics who have periodontal disease should be treated to eliminate the periodontal infection.51*CARDIOVASCULAR AND THROMBOEMBOLIC DISEASE:Periodontal disease has been linked to the occurrence of atherosclerosis and thromboembolic events including myocardial infarction and stroke. Patients with cardiovascular disease and periodontitis share many of the same characteristics including they are predominately older males, often with a history or smoking or high-stress occupations. One suggestion is that underlying inflammatory responses to the release of endotoxins by oral bacterial infections may induce atherogenic changes in the vascular system distant from the site of infection.52 But other evidence suggests a more direct linkage; Porphyromonas gingivalis (PG), a Gram-negative anaerobic microorganism associated with periodontal disease, has been detected in human coronary atheroma. Despite this finding, the cause-and-effect relationship between the occurrence of PG and coronary artery disease remains controversial as many other factors, such as smoking appear to put the individual at risk of developing both conditions.53Whatever the cause, there is a well established correlation between the occurrence of periodontal disease and atherosclerosis - thromboembolic events. At worst, the occurrence of periodontal disease may be an indication of a patients risk for cardiovascular diseases. At best, treatment or prevention of periodontal disease may lessen that risk.54*OSTEOPOROSIS:There is also a probable link between Osteoporosis and bone loss in the jaw. Osteoporosis may lead to tooth loss because the density of the bone that supports the teeth may be decreased, which means the teeth no longer have a solid foundation. However, hormone replacement therapy (HRT) may offer some protection. Reinhardt et al., 1997, conclude that estrogen supplementation in women within five years of menopause slows the progression of periodontal disease. Researchers have suspected that estrogen deficiency and osteopenia - osteoporosis speed the progression of oral bone loss following menopause, which could lead to tooth loss. The study concluded that estrogen supplementation may lower gingival inflammation and the rate of attachment loss including destruction of the fibers and bone that support the teeth in women with signs of osteoporosis, thus helping to protect the teeth. It is important to note that the safety and effectiveness of HRT has recently been called into question. In 2002, the National Institutes of Health (NIH) stopped its trial of the effectiveness of estrogen plus progestin HRT because of an increased risk of breast cancer. Because the risk of breast cancer, coronary heart disease, stroke and blood clots outweighed the benefits of hip fracture and colorectal cancer. More recently in 2004, testing of estrogen alone HRT was stopped because it did not appear to either increase or decrease and thus, affect heart disease while increasing the risk of stroke. According to the NIH, The increased risk of stroke in the estrogen-alone study is similar to what was found in the WHI (Womens Health Initiative) study of estrogen plus progestin when that trial was stopped in July 2002. In that study, women taking estrogen plus progestin had eight more strokes per year for every 10,000 women than those taking the placebo. The NIH believes that an increased risk of stroke is not acceptable in healthy women in a research study. This is especially true if estrogen alone does not affect, neither increase nor decrease heart disease, as appears to be the case in the current study. While HRT continues to be regarded as an effective preventative of postmenopausal osteoporosis, the NIH further advises, Therapy should only be considered for women at significant risk of osteoporosis who cannot take non-estrogen medications. The FDA recommends that estrogens and progestins should be used at the lowest doses for the shortest duration needed to achieve treatment goals.55*RESPIRATORY DISEASES:Bacteria that grow in the oral cavity can be aspirated into the lung to cause respiratory diseases such as pneumonia, especially in people with periodontal disease. Bacteria found in the throat, as well as bacteria found in the mouth, can be drawn into the lower respiratory tract. This can cause infections or worsen existing lung conditions. People with respiratory diseases, such as chronic obstructive pulmonary disease, typically suffer from reduced protective systems, making it difficult to eliminate bacteria from the lungs.56-57