Presented by :

Dr. Swarnali Biswas, PG 1st year

Department of Prosthodontics
Chandra Dental College and Hospital
 Introduction
 Bone
 Temporomandibular Joint (TMJ)
 Nerves and musculature
 Oral mucosa
 Taste and smell
 Salivary glands
 Teeth
 Conclusions
 Worldwide population demographics are changing rapidly and the
proportion of older people is growing faster than any other age group.
 Globally, poor oral health among older people has traditionally been
manifest in high levels of tooth loss, dental caries and periodontal
disease experience, as well as xerostomia and oral precancer/cancer.
 In addition, evidence of the relationship between oral health and poor
general health continues to grow with links between severe periodontal
disease and diabetes mellitus, ischaemic heart disease and chronic
respiratory disease the focus of much research.
 Age changes are manifest in the oral and dental tissues.
 What is seen is a combination of physiological age changes with
superimposed pathological and iatrogenic effects.
 The masticatory apparatus compromises :
1. Bone
2. Temporomandibular Joint (TMJ)
3. Nerves and musculature
4. Oral mucosa
5. Taste and smell
6. Salivary glands
7. Teeth
Flow chart summarising the main ageing changes induced by age in the eating process. (+), Positive tendency of the
relationship; (–), negative tendency of the relationship; (?), partially known or unknown consequences.
 Increasing age is associated with
progressive reduction in bonemass
resulting in osteoporosis.
 Agerelated osteoporosis is common
and, in edentulous patients, may play
a role in atrophy of alveolar and
possibly basal bone.
 Atrophy of alveolar bone is related
mainly to tooth loss. Extent of alveolar bone height following loss of
lower teeth.
 Its extent increases with age resulting,
in the absence of dentures, in loss of
facial height with upwards and
forwards posturing of the mandible.
 Loss of alveolar bone is more extensive
and occurs more rapidly in the
mandible than in the maxilla.
 Levels of the cyclo-oxygenase 2 (COX
2) enzyme, which plays an essential
role in bone repair, decline
dramatically with ageing. This may Patient exhibiting loss of vertical face height due to
explain the delayed bone healing that overclosure and posturing of the mandible.
occurs in older patients.
 Research is now being conducted to
stimulate activity of the COX 2 enzyme
and subsequent bone healing.6

Atrophy of a lower edentate mandible

 Residual ridge resorption
Definition: The diminishing quantity
and quality of the residual ridge after
teeth are removed (GPT8).
 Classification
Atwood classified the progression of
residual ridge resorption (RRR) as
follows:
• Order 1: Pre extraction
• Order 2: Post extraction
• Order 3: High, well rounded
• Order 4: Knife-edged
• Order 5: Low, well rounded
• Order 6: Depressed
Resorption pattern
 Generally women show more
RRR than men.
 During the first year following
extraction, reduction in
residual ridge height is 2–3 mm
in maxilla and 4–5 mm for
mandible. After this, the
process will continue but with
reduced intensity.
 Mandible shows 0.1–0.2 mm
resorption annually, which is
four times more than
edentulous maxilla.
 The maxillae resorb upward
and inward to become
progressively smaller because
of the direction and inclination
of the roots of the teeth and
the alveolar process. The longer
the maxillae have been
edentulous, the smaller their
bearing area is likely to be.
 The opposite is true of the
mandible, which inclines
outward and becomes
progressively wider according
to its edentulous age. This Progressive resorption of the maxillary and mandibular
progressive change of the ridges makes the maxillae narrower and the mandible
edentulous mandible and wider. The lines A and B represent the centers of the
maxillae makes many patients ridges. The distance between them becomes greater as
appear prognathic. the mandible and maxillae resorb.
Aetiology
 It is assumed that the degree of residual ridge reduction results from a
combination of anatomical, metabolic, and mechanical determinants.
 Severe residual ridge reduction of the mandible has been related to a
small gonial angle (a marked mandibular base bend and a posterior
position of the lower incisal edges in relation to the mandibular body).
 Progressive loss of bone under dentures is a manifestation of
osteoporosis.
 There is a strong association between the skeletal bone density and bone
density of the mandible, and the mandible is also affected by
osteoporosis.
 Low bone mineral content and osteoporotic changes predispose to a more
rapid residual ridge reduction, particularly in the maxilla.
 The mechanical factors (masticatory or parafunctional forces)
transmitted by the denture or the tongue to the residual ridge are
assumed to be important factors in the remodeling process.
Consequences of residual ridge reduction
 Loss of sulcus width and depth
 Displacement of the muscle attachment closer to the crest of the
residual ridge
 Loss of the vertical dimension of occlusion
 Reduction of the lower face height
 Anterior rotation of the mandible
 Increase in relative prognathia
 Changes in interalveolar ridge relationship
 Morphological changes : sharp, spiny, uneven residual ridges and
location of the mental foramina close to the top of the residual ridge.
 Reduced mechanical load due to tooth loss affects the density, stiffness, and
strength of bone structure (Giesen et al. 2003).
 Remodelling may result in disc displacement, particularly anterior
displacement.
 The retrodiscal tissues may show adaptive changes associated with decreased
cellularity and vascularity, and increased density of collagen, and may
eventually function as an articular disc.
 In some cases the displacement may lead to perforation of the disc, particularly
of its posterior attachment, resulting in progressive joint damage.
 The difference between dentate and edentulous subjects involves bone mass,
morphology, and mechanical properties of components of the masticatory
system, e.g., teeth, muscles, mandibular condyles, and the position of the
glenoid fossa (Hongo et al. 1989, Kawashima et al. 1997, Raustia et al. 1998,
Bassi et al. 1999,Giesen et al. 2003).
Te= temporal bone, Co= condyle. (A) Normal condyle of the tempomandibular
joint, (B) flattening of the articular surface of the condyle, (C) subcortical
sclerosis, (D) osteophyte, (E) microcyst, (F) marginal erosion, (G) periarticular
ossicle, (H) deformity (By permission of Peltola 1995).
 Age Changes in the Mandible
The morphology of the mandibular condyle varies considerably both in size and shape
greatly among different age groups and individuals. This is due to developmental
variability as well as remodeling of condyle to accommodate malocclusion,
developmental abnormalities and diseases.
The most prevalent morphologic changes are detected in the TMJ of elderly persons
due to the onset of joint degeneration. The shape of the condyle may be
categorized into five basic types: Flattened, convex, angled, rounded, and concave.
 At birth
The angle is obtuse (175°), and the condyloid portion is nearly in line with the body.
The coronoid process is of comparatively large size and projects above the level of
the condyle.
 Childhood
The angle becomes less obtuse, owing to the separation of the jaws by the teeth; about
the 4th year, it is 140°.
 Old age
The neck of the condyle is more or less bent backward in old ages. Disc displacement,
perforation, disc deformation, and arthrosis seem to increase with age.
 Age Changes in Disc
At the age of 9-10 weeks, the articular disc has a more cellular structure with an
irregular arrangement of fibers.
At the 11th week, the disc consists of fusiform cells, which are located mainly on its
surface and densely arranged collagenous fibers.
At the 12th week, the shape of disc changes into a thinner central part and a thickened
peripheral part.
The histological study shows avascular anterior part of the disc and is composed of
woven fibrous tissue, whereas the posterior part is of looser texture and may be
subdivided into an upper zone rich in elastic tissue and a lower zone, which has
many large blood vessels.
As age advances, there is a progressive decrease in cellularity and an increase in collagen
fibers in the disc. The disc becomes thinner and shows hyalinization and chondroid
changes.
 Age Changes in Synovial Fluid
Become fibrotic with thick basement membrane changes in blood vessels and nerves in
TMJ:
• Walls of blood vessels thickened
• Nerves decrease in number.
 These age changes lead to:
1. Decrease in the synovial fluid
formation.
2. Impairment of motion due to
decrease in the disc and capsule
extensibility.
3. Decrease the resilience during
mastication due to chondroid changes
into collagenous elements.
4. Dysfunction in older people.
 Muscle function is dependent on the performance of the nervous
system and both exhibit independent age-related changes.
 Nerve cell loss is universal in old age and is exhibited in the brain and
spinal cord.
 There are also age-related changes in neurotransmitters, resulting in
motor dysfunction.
 Peripheral nerve function declines with age as there is a reduction
in conduction velocity, increased latencies in multi-synaptic pathways,
decreased conduction at neuromuscular junctions and loss of
receptors.
 Continued muscle function is a major requirement for the maintenance of
speech and mastication.
 In all patients with advancing age there is a reduction in total muscle mass
which occurs through a reduction in the number of muscle fibres rather
than a major reduction in muscle fibre size.
 Electrophysiological studies have shown a loss of motor units with age,
particularly in those over the age of 60 years, which manifests as a reduction
in muscle strength and reduced masticatory forces.
 Age induces a lengthening of the chewing process associated with a
reduction in muscle activity, suggesting that elderly patients adapt their
chewing behaviour to changes in chewing activity.
 This affects foods such as dry bread or meat that are hard to chew (Kohyama et
al. 2002; Mioche et al. 2002b) but not foods that are easy to chew, such as
gelatine gels (Hatae et al. 2001).
 Older persons also have a less
coordinated chewing stroke close to
maximum intercuspation, probably
because of a general deficit in the central
nervous system, and some individuals
who assume the characteristic stoop of
old age experience pain on swallowing
because of osteophytes and spurs
growing on the upper spine adjacent
to the pharynx.
 A noticeable change in swallowing
strongly suggests that there might be an
underlying pathosis, such as
Parkinson’s disease or palsy that is not
a part of normal aging (Sonies, 1992).
 The stratified squamous epithelium becomes
thinner, loses elasticity, and atrophies with
age. A declining immunological
responsiveness further increases the
susceptibility to infection and trauma.
 An increased incidence of oral and systemic
disorders, along with increased use of
medications, may lead to oral mucosal disorders Chronic candidal infection
in elderly persons. Elderly patients may develop under a full upper
vesiculobullous, desquamative, ulcerative, prosthesis.
lichenoid and infectious lesions of the oral
cavity.
Denture stomatitis
 It is a pathological reaction of the denture-bearing
mucosa.
 It is also known as denture-induced stomatitis,
denture sore mouth,
inflammatory papillary hyperplasia or chronic atrophic candidiasis.
 Classification (newton)
Type 1: Localized simple inflammation or pin-point hyperaemia.
Type 2: Erythematous or generalized simple type presenting a more diffuse
erythema involving a part or the entire denture-covered mucosa.
Type 3: Granular type (inflammatory papillary hyperplasia) commonly
involving the central part of the hard palate and the alveolar ridges. It is
often seen associated with type 1 or type 2.
Candida albicans is most often
associated with denture
stomatitis along with the other
causative factors. It is then termed
as Candida-associated denture
stomatitis.
The diagnosis of Candida-
associated denture stomatitis is
confirmed by the presence of
mycelia or pseudohyphae in a direct
smear and/or the isolation of
Candida in high numbers from the
lesion (>50 colonies).
Oral cancer
 Predisposing factors
Use of heavy alcohol and tobacco, uneducated
and low socioeconomic status, which lead to poor
dental health.
 Oral cancer is primarily a disease of ageing and
associated cell dysregulation.
 It is estimated that more than 90% of all oral
cancers in developed countries occur in individuals
older than 50 years, with a mean onset during the
sixth decade of life.
 Oral cancer is associated with high morbidity and a
particularly poor survival rate of less than 50% after
5 years.
Burning mouth syndrome
 Definition
Burning pain in the tongue or other oral
mucous membrane associated with normal
signs and laboratory findings lasting at least
4–6 months (International Association for
the Study of Pain).
 In this condition, the oral mucosa appears
clinically healthy.
 It must be differentiated from ‘burning
mouth sensations’ where the oral mucosa is
inflamed due to mechanical denture
irritation.
Angular cheilitis
 Angular cheilitis is a multifactorial disease affecting the commissure of the
lips and is commonly seen in denture wearers.
 Aetiology
• Loss of vertical dimension or worn-out dentures – deep folds of skin are
produced at the corners of the mouth. The skin becomes macerated and
fissured, predisposing to infection – usually candidal or staphylococcal.
• Nutritional deficiencies such an iron deficiency, vitamin B.
• Other uncommon predisposing factors include AIDS, diabetes and
neutropenia.
 Clinical examination
• Deep fissures and cracks at the corners of the mouth that may be ulcerated.
A superficial exudative crust may form.
• The fissures do not involve the mucosa on the inside of the mouth, but stop
at the mucocutaneous junction.
• Associated burning sensation or dryness at the corners.
Angular cheilitis seen at the commissure of the lips.
 The scars of a lifetime are revealed dramatically on the skin as wrinkles,
puffiness, and pigmentations, but the changes are not all manifestations of
degeneration.
 Fewer Langerhans’ cells in older skin can prevent undesirable
immunological responses.
 Mottling of the skin protects against the sun.
 The leathery look characteristic of the older sun worshipper is caused by
epidermal growths with large melanocytes—solar lentigines— that thicken
in the epidermis.
 Gradually the dermis thins, enzymes dissolve collagen and elastin, and
wrinkles appear when layers of fat are lost.
 Age reduces the concavity and “pout”
of the upper lip, and it flattens the
philtrum.
 The nasolabial grooves deepen, which
produces a sagging look to the middle
third of the face, whereas atrophy of
the subcutaneous and buccal pads of
fat hallows the cheeks.
 Subsequently, as the loss of fat
continues, support for the Appearance of the lower two thirds of an
presymphyseal pad of fat disappears, elderly person’s face demonstrating the
typical droop of the upper lip that
and the upper lip droops (cheiloptosis) accentuates the mandibular incisors
over the maxillary teeth.
 These changes are accentuated even more dramatically when teeth are
missing or when there is a loss of occlusal vertical dimension.
•Sensitivity to taste declines with age,
and especially in older persons with
Alzheimer’s disease (Murphy, 1993).
•Also, the preference for specific flavors
changes over time to favor higher
concentrations of sugar and salt.
•Complaints of an impairment affecting
the sense of taste at any age should be
investigated thoroughly because they
forebode an upper respiratory infection
or a serious neurological disorder.

Possible causes of olfactory and taste disorders.

 Most studies suggest that the sense of smell is more impaired by ageing
than the sense of taste.
 Olfactory cells which respond to smells are renewed much more slowly in
elderly people.
 Olfactory acuity declines with age as the number of olfactory nuclei in the
brain decline and the olfactory receptors in the roof of the nasal cavity
regress.
 As a result, older people generally have greater difficulty differentiating
among food odours than younger people.
 A diminution of taste results from the degeneration of taste buds and a
reduction in their total number as renewal is much slower in elderly
people.
 Elderly people have considerable differences in their sensory perception
and capacity to detect the pleasantness of foods compared with younger
people.
 This can lead to older people adding ingredients such as sugars or salt to
foodstuffs which can have adverse health effects.
 Complaints of a dry mouth
(xerostomia) and diminished
salivary output are common in
older populations.
 Estimates of xerostomia and
salivary hypofunction indicate that
approximately 30% of the
population 65 years and older
experience these disorders and
their accompanying oral and Oral and pharyngeal consequences
of salivary hypofunction.
pharyngeal consequences.
 The most common cause of salivary disorders is the use of prescription and
non-prescription medications.
 Reports indicate that 80% of the most commonly prescribed medications
can cause xerostomia, with more than 400 medications associated with
salivary gland dysfunction as an adverse side-effect.
 Because elderly people are more likely than the rest of the population to
take medications and are more vulnerable to their side-effects,
medication-induced xerostomia is not uncommon.
 Drugs with anticholinergic effects are the most likely to produce
complaints of diminished salivary output and dry mouth.
 Drugs that inhibit neurotransmitters from binding to salivary gland
membrane receptors, or that perturb ion transport pathways in the acinar
cell, may adversely affect the quality and quantity of salivary output.
 Common categories of these drugs include:
1. Tricyclic antidepressants
2. Sedatives and tranquillizers
3. Antihistamines
4. Antihypertensives
5. Cytotoxics
6. Anti-Parkinsonism drugs
 One treatment for head and neck cancers is external beam radiation,
which causes severe and permanent salivary hypofunction and results in
persistent complaints of xerostomia.
 Radiation-induced destruction of the serous-producing salivary cells
occurs via apoptosis.
 Within one week of the start of irradiation, a patient’s salivary output may
have declined by 60–90%, with no recovery occurring unless the total dose
to salivary tissues is less than 25 Gy.
 Most patients receive therapeutic dosages that exceed 60 Gy, therefore
their salivary glands undergo atrophy and become fibrotic.
 Numerous systemic medical conditions can cause or contribute to salivary gland
diseases.
 Including:
1. Sjögren’s syndrome;
2. Diabetes mellitus;
3. Alzheimer’s disease; and
4. Dehydration
 Sjögren’s syndrome is one of the most frequently encountered chronic
autoimmune connective tissue disorders and is the most common systemic
condition associated with xerostomia.
 Sjögren’s syndrome occurs in primary and secondary forms.
 Those patients with primary Sjögren’s syndrome have salivary and lacrimal gland
involvement, with an associated decreased production of saliva and tears.
 In secondary Sjögren’s syndrome, the disorder presents with other autoimmune
diseases, such as rheumatoid arthritis, systemic lupus erythematosis and
scleroderma.
 Epidemiological studies show that the prevalence and
severity of periodontal disease increases with age.
 This is most likely the result of repeated episodes of active
destruction occurring over time rather than an intrinsic Evidence of
change associated with the ageing process itself. gingival
 Periodontal changes attributable solely to advancing age recession in an
elderly patient
are not sufficient to account for tooth loss, especially in a
leading to
healthy adult.
exposure of
 Gingival recession has been considered as an age change, root surfaces
but it is now known to be part of the clinical spectrum of and root caries.
periodontitis in which plaque is the main aetiological
agent.
 There is no evidence that the
elderly are particularly susceptible
to periodontal disease, although
confounding variables such as
systemic diseases, reduced manual
dexterity, oral factors and
medications have an adverse effect
on periodontal health.
Poor oral hygiene observed in an older patient
attending geriatric day hospital
 Age changes in teeth include
physiological wear with
superimposed changes in
morphology associated with
pathology, including attrition and
changes in the structure and
composition of the dental hard
tissues.
Toothwear of lower incisors in an elderly
patient (the dentine deposition
obliterating the pulp chamber).
Enamel
 The enamel tends to become more
brittle and susceptible to chipping,
cracking and fracture.
 It also becomes less permeable with
age, reflecting the ionic exchange
which occurs between enamel and the
oral environment throughout life. Staining of lower anterior
 Darkening of the enamel and staining teeth in an elderly patient.
has also been described and may be
due to absorption of organic material.
Dentino-pulpal complex
 The two main age-related changes in dentine are continued formation of
secondary dentine, resulting in reduction in size and in some cases
obliteration of the pulp chamber, and dentinal sclerosis associated with the
continued production of peritubular dentine.
 Both of these processes are also associated with caries and toothwear.
 Dentine sclerosis may affect the use of adhesive systems with dentine.
 Sclerosis of radicular dentine tends to make the roots brittle and they may
fractureduring extraction.
 It is also associated with increased translucency of the root.
 This starts at the apex in the peripheral dentine just beneath the cementum
and extends inwards and coronally with increasing age.
 Physiological age changes are as a result of
continued production of secondary
dentine.
 This reduces the height of pulp horns,
makes the pulp shrink out of the crown
and anterior teeth, reduces the distance
between chamber roof and floor in
posterior teeth and causes the pulp to
Pulp chambers of a 70-year-old patient
narrow concentrically in roots. showing a reduction in depth of the pulp
chambers.
 The diminishing pulp space can be further
complicated by the growth of irregular
calcifications around degenerating blood
vessels and nerve cells.
 These changes usually comprise spheroid ‘pulp
stones’ in the coronal chamber and linear
deposits in the canals.
 Radiographs may suggest that these changes
completely obliterate the pulp space, but they
are usually interspersed with soft tissue that
provides space and nutrition for microbial Pulp stones in maxillary molar teeth.
infection, whilst easing the path for operative
disruption and entry.
 Pulps undergo physiological and reactive
changes as patients age.
 Changes are not uniform and are not uniquely
concentrated in the chronologically old.
 Pulp canals in the elderly are not necessarily
narrow and difficult to manage, and reactive
changes in the young and middle-aged can be
equally challenging.
 As the pulp ages, it becomes less vascular, less
cellular and more fibrotic, resulting in a
reduced response to injury and decreased
healing potential.
 There is also a reduced nerve supply which, together with a greater
thickness of dentine, makes vitality testing more difficult.
 The tissue is tougher and may not be penetrated as easily with files.
 The risk this presents is that entry, even to a seemingly large pulp, results
in compaction of pulp tissue to form a dense collagenous plug that is as
impregnable as any calcified deposit.
 There is special merit in the elderly of removing pulp tissue with barbed
broaches and the routine use of lubricants to allow instruments to glide
through tissue rather than compacting it.
Cementum
 Cementum continues to be formed throughout life, especially in the apical
half of the root, resulting in a gradual increase in thickness to compensate
for interproximal and occlusal attrition and in response to trauma, caries
and periodontal disease.
 The amount of secondary cementum at the apex of a tooth is a factor that
can be taken into account in radiographic working length estimation in
endodontics, and in forensic dentistry in age estimation.
 Increased amounts of cementum along with secondary and reparative
dentine diminish tooth sensitivity and reduce perception to painful
stimuli.
 A variety of oral changes may be observed in elderly patients.
 These changes can be attributed to a variety of physiological and
pathological processes which have developed over a lifetime.
 Clinically, it is important to recognize these changes and to develop
planning strategies which take account of them.
 Emphasis must be placed on preventive regimes and treatment delivery
which is sympathetic to the changing needs of our existing elderly and
ageing population.
 Boucher’s prosthodontic treatment for edentulous patients.(9th edition) -Zarb &
Bolender
 Textbook of complete denture (5th edition) – Charles M Heartwell Jr & Rahn
 Essentials of complete denture prosthodontics - Sheldon Winkler
 Text book of Prosthodontics (2nd ed.) – V. Rangarajan & TV Padmanabhan
 Gerald Mckenna & Francis M Burke ; Age-Related Oral Changes, Dent Update
2010; 37: 519–523
 Laurence Mioche*, Pierre Bourdiol and Marie-Agnès Peyron ; Influence of age
on mastication: effects on eating behaviour, Nutrition Research Reviews (2004), 17,
43–54