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11 AUTHORS, INCLUDING:
Rosario Guiglia
Lucio Lo Russo
SEE PROFILE
SEE PROFILE
Lorenzo Lo Muzio
Giuseppina Campisi
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619
Department of Oral Sciences, University of Palermo, Italy; 2Oral Sciences Institute of Polytechnic University of Marche, Ancona,
Italy; 3Department of Surgical Sciences, University of Foggia, Italy; 4Department of Clinical Medicine and Emerging Diseases,
University of Palermo, Italy.
Abstract: Changing demographics, including an increase in life expectancy and the growing numbers of elderly has recently focused
attention on the need for geriatric dental care. Ageing affects oral tissues in addition to other parts of the human body, and oral health
(including oral mucosa, lips, teeth and associated structures, and their functional activity) is an integral component of general health;
indeed, oral disease can cause pain, difficulty in speaking, mastication, swallowing, maintaining a balanced diet, not to mention
aesthetical considerations and facial alterations leading to anxiety and depression. The World Health Organization recommends the
adoption of certain strategies for improving the oral health of the elderly, including the management and maintenance of oral conditions
which are necessary for re-establishing effective masticatory function. Oral health is often neglected in the elderly, and oral diseases
associated with aging are complex, adversely affecting the quality of life. Although oral health problems are not usually associated with
death, oral cancers result in nearly 8,000 deaths each year, and more than half of these occur at an age of 65 years plus. This report, which
is dedicated to geriatric physicians, geriatric dentistry and specialists in oral medicine reviews age-related oral changes in elderly patients
and efforts to summarize the effects of aging in hard and soft oral tissues.
Keywords: Ageing, oral health, quality of life, geriatrics, dental care, oral medicine, elderly, oral mucosal conditions, periodontal diseases;
salivary glands; burning mouth syndrome.
INTRODUCTION
Ageing is an inexorable process which causes homeostasis
disequilibrium, increased vulnerability, in addition to reduced
adaptation to environmental stimuli, affecting cells, tissues, organs
and bodily systems. All these phenomena are associated with an
increased predisposition to illness and death. The debate continues
as to whether the physiologic and pathologic changes characterizing
ageing are due to the ageing process itself or to diseases,
medications, or environmental changes to which ageing people are
exposed. For certain, the global proportion of older people is
growing faster than of any other age group with approximately 600
million people aged 60 years and over, and this number will double
by 2025. This implies that, with more people living longer, there
will also be an increase in the prevalence of systemic and oral
diseases which need to be addressed for effective prevention,
therapy and rehabilitation.
Ageing per se exerts various effects on oral tissues and
functions. The elderly are at risk of chronic diseases of the mouth,
including dental infections (e.g., caries, periodontitis), tooth loss,
benign mucosal lesions, and oral cancer. Other common oral
conditions to be found in this population are xerostomia (sensation
of dry mouth) and oral candidiasis, which may may manifest itself
as acute pseudo-membranous candidiasis (thrush), erythematous
lesions (denture stomatitis), or angular cheilitis.
Generally, the most common oral condition in the elderly is
tooth loss due to dental caries or periodontal disease (PD). Indeed,
the number of teeth in the arches is considered as a measure of oral
health status, since retaining less than 20 teeth causes masticatory
difficulties and reduced swallowing. Many systemic conditions
(e.g., xerostomia, orofacial pain and oral and pharyngeal cancer,
typical in the elderly) and socio-economic factors (e.g., costs,
educational background, social class) interfere with the maintenance of a functioning dentition and a healthy oral cavity may
have local and systemic effects/implications [1].
Dentition
External and internal tooth changes
Coronal and root surface caries
Periodontal Tissues
Gingivitis
Periodontitis
Tooth-alveolar abscess
Alveolar Bone
Atrophic mandible (Alveolar Bone loss, ABL)
Osteoporosis and Bisphosphonate-Related Osteonecrosis of
the Jaw (BRONJ)
Osteoradionecrosis and radiotherapy
Fracture
DENTITION
External and Internal Tooth Changes
Changes in dentition due to the ageing process can be attributed
to normal physiologic processes and to pathologic changes in
response to functional and environmental factors. External tooth
changes include discoloration (from yellow to brown) and enamel
loss due to abrasion, erosion or occlusal attrition [3] (Fig. 1a).
Thinning around the neck of teeth, often related to the use of hardbristled toothbrushes over many years of improper tooth brushing,
is frequently observed [17].
Severe enamel wear will ultimately expose underlying dentin,
which produces sclerotic and secondary dentin [18] in response to
trauma and caries. Over time, the number of blood vessels per tooth
and the thickness of the enamel are reduced, leading to decreased
sensitivity; dentin undergoes a reduction in thermal, osmotic, and
electrical sensitivity, and pain perception.
The susceptibility to caries decreases, the cementum (i.e. the
substance covering the root surface) gradually thickens and pulp
Guiglia et al.
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Guiglia et al.
Fig. (1). a) Diffuse caries associated with discoloration, b) Gingivitis, c) Chronic periodontitis d) Dento-alveolar abscess.
623
Salivary Glands
Obstructions
Hypofunction
Bacterial infectious
Neoplasia
Others
Burning mouth syndrome (BMS)
order to indicate that not all lesions and conditions described under
the term precancerous may transform to cancer, but rather there is
a family of morphological alterations (e.g., epithelial precursors), of
which some may have an increased potential for malignant
transformation (Table 2) [89].
Table 2. Potentially Malignant Lesions of Oral Mucosa
Modified by Warnakulasuriya S. et al. [89].
Lesions
Conditions
Leukoplakia
Actinic keratosis
Erytroplakia
Lichen planus
Cancer
Oral cancer can occur more frequently in older individuals and
can affect the lips, gum tissues, cheek lining, tongue, hard and soft
palates, pharynx and floor of the mouth. Ninety-five percent of oral
and pharyngeal cancers occur after the age of 40 years [90], and
persons 65+ years are 7 times more likely to be diagnosed with oral
cancer than persons under 65 years of age [91]. Tobacco and
alcohol use are considered to be responsible for up to 75% of oral
cancers [92] but diets low in fruit and vegetables, the potential role
of the human papillomavirus (HPV), the influence of immunosuppression, genetic mutations and PML (primarily leukoplakia)
can all be implicated in these types of cancer [93]. Most oral and
oropharyngeal cancers are squamous cell carcinomas that arise
from the lining of the oral mucosae. PML and oral cancer can
appear as insignificant and asymptomatic lesions. A lesion may
begin as a white or red-colored patch, progress to ulceration, and
eventually become an endophytic or exophytic mass. Patients with
any white or red lesion that persists for longer than two weeks
should be referred to an oral medicine specialist for careful
evaluation [94].
Vesciculobullous Diseases
In the current PD(s) classification system, gingival manifestations of systemic conditions [35] have been included among nonplaque induced gingival disorders. Several mucocutaneous disorders and vesciculobullous diseases (i.e. lichen planus, pemphigoid,
pemphigus vulgaris, erythema multiforme, lupus erythematosus,
drug-induced lesions and others) are listed in this subgroup,
together with allergic reactions to dental materials, foods, and other
substances for topical application. Besides their heterogeneous
nature, all these disorders share two features: an immuno-mediated
pathogenesis and a possible common clinical manifestation, socalled desquamative gingivitis (DG). The term DG indicates the
presence of areas of atrophy, erythema, desquamation, erosion and
vesiculobullous lesions of the attached gingiva, of both anterior and
posterior areas, regardless of aetiopathogenesis. DG is a clinically
relevant entity as it can affect oral health and be a feature of
systemic disease [95].
Ulcerative Diseases
Compilato et al. [96] have proposed a new simple, complex
and destroying classification system (S-C-D system) in a recent
review for ulcers in clinical dental practice. Gingival ulcers have
various aetiologies and they may be due to, self-injury in
psychologically-disturbed or mentally-challenged patients, malignant neoplasms, drugs, dermatoses, or systemic diseases (e.g.,
hematological, mucocutaneous, gastrointestinal, or chronic infections such as tuberculosis, syphilis, mycoses, herpes viruses HIV)
[97].
Guiglia et al.
625
Fig. (2). a) Orthopantomogram showing marked resorption of the alveolar arches, b) Multiple ulcers in a case of RAS, c) Angular cheilitis
Hypofunction
Saliva is a key element in oral homeostasis, oral function and
the maintenance of oral health. Saliva is involved in multiple
functions such as taste, mastication, deglutition, digestion,
maintenance of oral hard and soft tissues, control of oral microbial
populations, voice and speech articulation [120]. Reductions in
salivary flow (<500 mL in 24-hour) most commonly manifest as
symptoms of oral dryness [121]. It is important to distinguish
between two terms which are often erroneously used as synonyms
in clinical practice: a) xerostomia, indicating a subjective complaint
of a dry mouth; and b) hyposcialia, referring to objective alterations
in salivary performance, quantitative or qualitative, and thus to a
salivary gland dysfunction. Although xerostomia is most often
indicative of reduced salivary output, it is not invariably associated
with objective salivary gland hypofunction. Conversely, the
absence of symptoms of dry mouth is not a guarantee of adequate
salivary function.
Alterations in salivary function lead to a compromising of oral
tissues and functions and they can exert a great impact on a
patients quality of life. Furthermore, hyposalivation can increase
the risk of oral infection (e.g., candidiasis, dental caries, periodontal
disease and tooth loss) [120]. Patients with hyposalivation could
refer thirst, halitosis, dysphagia and, in particular, difficulties
associated with eating dry foods (such as biscuits), an intolerance to
acid and spicy foods, nocturnal oral discomfort, chronic oropharyngeal burning, mucus accumulation, food retention in the mouth, and
plaque accumulation [120,122]. Hyposalivation is common in older
people and its prevalence increases with age, involving
approximately 30% of patients aged 65+ years [123]. The highest
prevalence of hyposalivation in older people could be explained by
the increased incidence of medication use and systemic disease in
this group. Whilst more than 500 drugs have been implicated in
inducing salivary gland hypofunction, few of these have been
demonstrated to affect salivary function in controlled clinical
studies [124].
Guiglia et al.
which makes this group the second most common site for salivary
neoplasia; unfortunately, a relatively high proportion (almost 50%)
of these tumour are malignant [134]. Minor salivary gland tumours
are distributed in the upper aero-digestive tract, in the palate,
paranasal sinuses and nasal cavity, tongue, floor of the mouth, lips,
gingiva, pharynx, larynx and trachea. Most of them are intra-oral,
with the palate as the most frequent site followed by the lips,
causing a painless submucosal swelling. The mucosal layer is
frequently adherent to the mass, often showing ulceration [96].
OTHERS
Burning Mouth Syndrome
According to the International Association for the Study of
Pain, burning mouth syndrome (BMS) (i.e. stomatodynia,
glossodynia, oral dysaesthesia) has been defined as a "distinctive
nosological entity" characterized by "unremitting oral burning or
similar pain in the absence of visible oral mucosa changes" [135].
Furthermore, BMS refers to a chronic neurosensory disorder
usually unaccompanied by mucosal lesions or other clinical signs of
organic disease [136-138].
BMS is a relatively common condition with a prevalence in the
general population ranging from 0.7% to 15%, increasing with age
[139, 140]. Scala et al. [137] have proposed a classification of BMS
into two clinical forms: primary BMS or essential/idiopathic
BMS, for which organic local or systemic causes cannot be identified, probably originating in the activation of neuropathological
mechanisms; and secondary BMS, which would be the variant
resulting from local or systemic pathological conditions susceptible
to aetiology-directed therapy.
The aetiopathogenesis of primary BMS seems to be complex
and probably involves interactions among local environmental
factors (salivary gland dysfunction and altered mucosal blood
flow), the peripheral nervous system, central nervous system and
psychosocial factors [141]. New interesting associations have
recently emerged between BMS and peripheral nerve damage.
Lauria et al. [142] have suggested that BMS may be associated with
trigeminal small-fiber sensory neuropathy. Of note is the role of the
gustative innervation of the tongue in the pathophysiology of BMS
related to the peripheral nervous system. Femiano et al. [143] have
suggested that, as a result of the interaction between the
mechanisms of nociception and gustation in the central nervous
system, it is possible that BMS and other oral pain phantoms
result from damage to the gustatory system.
Finally, data have suggested the involvement of the central
nervous system and its interaction with the peripheral nervous
system in the pathogenesis of BMS [137]. Several conditions may
lead to secondary BMS: infections, allergic reactions, galvanism,
dental treatments, parafunctional habits, and salivary gland
dysfunction [144,145]. Moreover, hormonal disorders correlated to
the menopause, diabetes and nutritional deficiencies are systemic
conditions which probably influence the prevalence, onset, and
severity of BMS [137,140].
CONCLUSION
The oral cavity is involved in several physiologic activities
[55,129,130,132,133,136-145], such as language, posture, mastication, swallowing, prosthetic retention. It has been established that
the process of ageing includes a general progressive decline in the
bodys total skeletal musculature mass and its performance, which
includes masticators and mimic facial muscles. Thus the aging
process may lead to dramatic changes in the condition of teeth, oral
mucosae, alveolar bone and salivary glands, even if age alone does
not seem to play an exclusive role in these impairments. Dental,
periodontal, oral mucosal, and salivary diseases have a detrimental
and compounding affect on oral health in elderly persons, yet oral
disease is not necessarily a concomitant of growing older.
VZV
Varicella-Zoster Virus
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ABBREVIATIONS
ADA
=
American Dental Association
ABL
=
Atrophic Bone Loss
BMS
=
Burning Mouth Syndrome
BPs
=
Bisphosphonates
BRONJ
=
Osteoporosis and Bisphosphonate-Related
Osteonecrosis of the Jaw
OP
=
Osteoporosis
ORN
=
Osteoradionecrosis
PD
=
Periodontitis
PML
=
Potentially Malignant Lesions
RAS
=
Recurrent Aphthous Stomatitis
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