AGING AND THE PERIODONTIUM

1. AGING AND THE PERIODONTIUM

2. CONTENTS • Introduction • Definition • Classification • General effects of aging • The aging periodontium • Periodontal disease in older adults • Effects of aging on periodontal disease progression • Periodontal treatment planning • Response to treatment of the periodontium • Conclusion

3. INTRODUCTION The increase in life expectancy brings an increase in periodontal disease expectancy. Meeting the oral health needs of the elderly requires understanding the biology of aging and the impact of aging on the periodontium. Demographic change makes this requirement increasingly urgent.

4. Definition Aging is a slowing of natural function, a disintegration of the balanced control and organization that characterize the young adult. Aging is the continuous process (biologic, psychologic, social) beginning with conception and ending with death, by which organisms mature and decline.

5. Chronologic age: The actual measure of time elapsed since a person’s birth. Biologic age: The anatomic or physiologic age of a person as determined by changes in organismic structure and function; takes into account features such as posture, skin texture, strength, speed and sensory acuity .

6. Classification According to chronologic age - “Older population” (age 55 and over) - The “elderly” (age 65 and over ) - The “aged” ( 75 years and older) - The “very old” ( 85 years and older)

7. General effects of aging • All tissues undergo certain changes as a result of aging . • Changes with aging vary among individuals and among organs and tissues of the same individual. • Reduction in vascularity, elasticity and reparative capacity are some of the common manifestations of aging.

8. Increased susceptibility to infection: May be related to • Lowered capacity in cell-mediated and humoral immunity. • Altered skin and mucosal barriers. In the oral cavity, the flora of the mucosa can be changed, especially when systemic conditions or medications lead to xerostomia. • Interaction of nutritional factors with the underlying chronic conditions.

9. Changes in response to disease: • Course and severity: In the elderly person disease may occur with greater severity and have a longer course with slower recovery. • Pain sensitivity may be lessened. • Temperature response may be altered so that a patient may be very ill without the expected increase in body temperature.

10. Healing • Decreased healing capacity • More prone to secondary infection

11. Oral findings in aging Soft tissues • Lips- tissue changes- dry purse string opening results from dehydration and loss of elasticity within the tissues. • Angular cheilitis It is not specifically an age related lesion, but it is frequently seen among elderly person. • Oral mucosa Surface texture is affected by changes in lubrication of the tissue with decreased secretion of the salivary and mucous glands.

12. Atrophic changes The tissue may become thinner and less vascular with a loss of elasticity. • Hyperkeratosis- White patchy areas may develop as a result of irritation from sharp edges of broken teeth, restorations or dentures and from use of tobacco. • Capillary fragility- Facial bruises and petechiae of the mucosa are common.

13. Tongue • Atrophic glossitis( burning tongue) Taste sensation: • Taste may be reduced or abnormal taste reactions may occur primarily in people with a disease condition. Sublingual varicosities • Deep, red, or bluish nodular dilated vessels on either side of the midline on the ventral surface of tongue. Xerostomia

14. Intrinsic changes: In the aging process by the action of gerontogene (telomere shortening ) the number of progenitor cells decreases. Thus the number of progenitor cells decreases and cell renewal takes place at a slower rate and with fewer cells. So the effect is to slow down the regenerative procedures. Stochastic changes With a loss of regenerative power ,structures become less soluble and more thermally stable. Somatic mutation lead to decreased protein synthesis and structurally altered proteins. Free radicals contribute to the accumulation of waste in the cell.All these changes produce a decline in the physiologic process of tissue.

15. Physiologic changes: Decrease in number of collagen fibers leads to a reduction or loss in tissue elasticity. A decrease in vascularity results in decreased production of mucopolysaccharides. Functional changes with aging: The cells of the oral epithelium and periodontal ligament have reduced mitotic activity and cells experience a reduction in metabolic rate. These changes affect the immune system and affect healing capacity and rate. Inflammation when present develops more rapidly and severly.

16. Changes in Gingiva and alveolar mucosa • Thinning and decreased keratinization of the epithelium. This results in increase in the epithelial permeability to bacterial antigens, and a decreased resistance to functional trauma. • Flattening of the rete pegs and altered cell density • Increased width of attached gingiva • Reduced or an unchanged amount of stippling

17. Reduced oxygen tension • Greater amount of intercellular substance • Atheriosclerotic vessels • The progressive exposure of the root surface with age has been called passive eruption or passive exposure. • Recession of the gingival margin may occur because of inflammatory periodontal disease or trauma.

18. Increasing age results in coarser and denser gingival connective tissue. Qualitative and quantitative change to collagen include 1) Increased rate of conversion of soluble to insoluble collagen, 2) An increase in tensile strength of collagen fibers 3) An increase in thermal contraction 4) A decrease in extensibility 5) A decrease in water control 6) An increased resistance to proteolytic enzymes.

19. Changes in Periodontal ligament • Decreased number of fibroblasts • Decreased organic matrix • Increased amount of elastic fibers • The staining characteristics of periodontal fibers are altered (The fiber bundles are thick and well organized. But are less distinct, since they contain fewer reticular or argyrophilic fibers.)

20. Hyalinization and chondroid degeneration Both the hyalinization and chondroid degeneration may be 1) casually related to or an accompaniment of a reduced vascular supply 2) response to injury

21. Epithelial rests in the PDL show altered forms of aggregates. • The width of the PDL is generally reduced as a result of continuous deposition of cementum if the tooth is unopposed (hypofunction) • The width will increase with excessive occlusal loading(as in partially edentulous jaw).

22. Changes in Cementum • A straight – line relationship has been shown between age and cementum thickness. • Cellular cementum is deposited in the apical third of the roots to compensate for attrition. • The frequent cemental tears seen in specimens of aging humans may be related to age changes in the ground substance of cementum,to reduced vascular supply, or to thickened and less extensible ligament fibers embedded in the cementum. .

23. There is irregularity in the surfaces of both the cementum and alveolar bone facing the PDL with advancing age Changes in Alveolar bone • Decreased vascularity • Gradual reduction in metabolic rate • Increased resorption activity • Decreased rate of bone formation • Osteoporosis

24. Changes inTooth-periodontium relationships: • Loss of tooth substance caused by attrition • Occlusal wear reduces cusp height and inclination with a resultant increase in the food table area and loss of sluice ways. • The rate of attrition may be coordinated with other aging related changes such as continuous tooth eruption and gingival recession. • If bone support is reduced the clinical crown become disproportionately long and exerts excessive leverage on the bone. By reducing the clinical crown length attrition appear to preserve the balance between the tooth and its bony support.

25. Wear of the teeth also occurs on the proximal surfaces, accompanied by mesial migration of the teeth. Proximal wear reduces the anteroposterior length of the dental arch by approximately 0.5 cm by age 40. Anteroposterior narrowing from proximal wear is greater in teeth that tapers towards the cervical aspect such as incisors. Attrition and proximal wear result in a reduced maxillary-mandibular overjet in the molar area and an edge to edge bite anteriorly.

26. Masticatory efficiency • Slight atrophy of the buccal musculature is seen. • Reduction in masticatory efficiency in aged individuals is more likely to be the result of unreplaced missing teeth. • Loose teeth • Poorly fitting dentures • An unwillingness to wear dentures • Reduced masticatory efficiency leads to poor chewing habits and digestive disturbances.

27. Bacterial plaque • Dentogingival plaque accumulation increase with age. • This may occur in part because areas of recession in older individuals may favour plaque accumulation.

28. For supragingival plaque no real qualitative differences have been shown for plaque composition. • Age modifies the composition of the subgingival microbiota. • Age modifies the risk of any given microbial composition for disease progression. • Higher tendency for inflammation was possibly due to altered hard tissue morphology.

29. Effects of aging on periodontal disease progression Where excellent oral hygiene is maintained age does not seem to be an important variable in periodontal disease status. Periodontal treatment planning The goal of periodontal treatment for both young and old patients is to preserve funtion and eliminate or prevent the progression of inflammatory disease. Response to Rx of the periodontium The successful Rx of periodontitis requires both meticulous plaque control by the patient at home and meticulous supragingival and subgingival debridement by the therapist.

30. The dental and medical assessment should include • Review of dental history • Review of medical history • Review of medication used • Extraoral and intraoral examinations • Risk assessments

31. CONCLUSION Periodontal diseases are among the most prevalent chronic infections in dentate older adults. Future oral health care trends will see increased numbers of older adults seeking periodontal therapy. Treatment planning for and managing the care of elderly patients can be complicated for a number of reasons. To understand the patients needs one must understand the environment in which the patient functions.

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