Ageing dentition 2024

Ageing Dentition Overview

Background

  • Ageing Dentition 2024 validated by NHS University of Birmingham Community Healthcare

Learning Outcomes

  • Understand the significant physiological, structural, and functional changes in ageing dentition and oral soft tissues.

  • Identify common problems associated with ageing oral health, particularly in elderly patients.

  • Appreciate the various treatment considerations and strategies that are important for providing dental care to elderly patients.

Population Change

  • The population of elderly individuals (aged over 60) in the UK has risen to approximately 14.5 million, reflecting an increasing life expectancy.

  • There is a notable trend of increased retention of natural dentition among the elderly, resulting from advances in dental care, preventive measures, and education.

  • Growing awareness regarding dental hygiene and aesthetic concerns leads to older adults seeking dental care more proactively.

Enamel - Revision

  • Enamel is the hardest and most highly mineralized tissue in the human body, comprising about 96% inorganic material (primarily hydroxyapatite, a form of calcium phosphate) and 4% organic material.

  • The enamel's resilience to decay is compromised by the dissolution caused by acidic byproducts of bacterial metabolism, which contribute to dental caries formation.

  • Enamel undergoes gradual changes over time, including a fine network of organic material that may influence its structural integrity.

Physiological Changes - Enamel

  • With age, enamel tends to exhibit increased discolouration, making teeth appear darker, and brittleness, which increases the risk of fracturing.

  • There is a reduction in permeability, affecting water retention, and the development of longitudinal and stress cracks, which can predispose individuals to dental issues.

  • Wear facets, caused by occlusal wear, act as indicators of long-term wear patterns on the enamel surface.

Dentine-pulp Complex - Revision

  • The dentine-pulp complex constitutes the bulk of the tooth structure. It is composed of approximately 70% inorganic content (primarily hydroxyapatite), 20% organic material (mainly Type 1 collagen), and 10% water.

  • Dentine provides significant flexibility, which is crucial in preventing the enamel from fracturing under stress.

Dentine-pulp Complex - Primary and Secondary Dentine

  • Primary Dentine: This is the bulk material that makes up the tooth and outlines the pulp chamber; the mantle dentine is less mineralized than other types of dentine.

  • Secondary Dentine: This forms after the root of the tooth has developed and is characterized by its irregular deposition which narrows the pulp chamber over time.

  • The asymmetric decrease in pulp chamber size due to secondary deposition is an essential consideration for the vitality of the tooth.

Tertiary Dentine

  • Tertiary dentine, also known as reactive or reparative dentine, forms in response to stimuli including caries or injury. The quality and quantity of this dentine can vary based on the intensity and duration of the stimulus received.

Physiological Changes – Dentine-pulp Complex

  • As individuals age, there is a notable reduction in the size of the pulp chamber and root canals, which can eventually lead to total obliteration of the root canal, thereby decreasing the tooth's blood supply.

  • Other changes include a decrease in nerve fibers, the development of dystrophic calcifications, which may contribute to increased resistance to environmental injury yet reduce the tooth's repair capabilities.

Periodontium - Revision

  • The periodontium consists of connective tissues that occur around the teeth, including the cementum, periodontal ligament (PDL), alveolar bone, and gingiva.

  • Cementum forms on the root dentine, and both primary and secondary types of cementum can be identified based on their mineral content and role.

  • The PDL experiences a decrease in fibroblast cells while collagen levels rise, which can lead to calcification and subsequently a wider PDL space.

Physiological Changes - Periodontium

  • The apical migration of the dentoalveolar junction can lead to gingival recession, posing further risks to oral health.

  • The periodontium naturally becomes more susceptible to resorption as part of the ageing process, which can affect overall oral health and dentition stability.

Salivary Glands - Revision

  • Salivary glands are vital structures that produce saliva, which plays a critical role in oral health, including lubrication, digestion, and antimicrobial action.

  • The major salivary glands include the parotid, submandibular, and sublingual glands.

Physiological Changes – Salivary Glands

  • Age brings about fatty and degenerative changes in both major and minor salivary glands. This contributes to issues like xerostomia (dry mouth), impacting patients' oral health activities.

  • Accumulation of connective tissue and lymphocytes is observed in these glands, indicating an age-related deterioration in function.

  • The presence of oncocytes, cells containing excessive mitochondria, may signify age-related changes within the glandular structure.

Physiological Changes – Jaws

  • Age is significantly correlated with a reduction in bone mass and an increased risk of osteoporosis, which can affect dental and general health.

  • Alveolar bone atrophy is particularly pronounced in patients who are edentulous (without teeth), directly impacting jaw stability.

  • Aging is also associated with a loss of muscle mass and strength in the jaws, further affecting the ability to maintain dentition effectively.

Physiological changes - TMJ

  • Changes in the temporomandibular joint (TMJ) are connected to the remodelling processes that occur in response to tooth loss.

  • There is potential for disc displacement within the joint, leading to osteoarthritis and additional joint damage over time.

Oral Mucosa - Revision

  • The oral mucosa functions as a protective barrier, provides sensation, aids in secretion, and contributes to thermal regulation.

Physiological Changes – Oral Mucosa

  • Age-related thinning of epithelial surfaces and a loss of filiform papillae on the tongue can lead to increased vulnerability to injuries and infections, such as candidiasis.

  • Abnormal taste perception is often noted in older patients, which may impact their nutrition and overall quality of life.

Physiological changes - Tongue

  • The loss of papillae can result in a smoother appearance of the tongue, leading to changes in taste sensation and sensitivity.

  • It is common for prominent veins to appear on the surface of the tongue with advancing age, which may be an entirely benign phenomenon.

Causes of Tooth Loss

  • The major factors leading to tooth loss in the elderly include extensive caries, periodontal disease, along with other financial and motivational barriers affecting access to dental care.

Treating the Elderly Patient

  • Effective communication is crucial when treating elderly patients to accommodate any hearing and visual impairments they may face.

  • Clinicians should also be mindful of the patient's cognitive abilities, emotional state, and overall health background when discussing treatment options.

Common Problems Associated with the Elderly

  • Root Caries: Difficult to restore and often exhibit a high recurrence rate compared to other forms of dental caries.

  • Tooth Wear: Increases over time leading to malocclusion and impacting function.

  • Failing Restorations: Older dental work may become plaque-retentive and require extra attention as patients age.

  • Xerostomia (Dry Mouth): This condition can lead to difficulties in swallowing, making oral health maintenance challenging.

  • Candida Infections: Often linked to poor health conditions and high rates of denture use among elderly patients.

  • Oral Hygiene Challenges: Impaired dexterity and lack of motivation in older patients often lead to increased plaque levels and oral health complications.

Orofacial Pain in the Elderly

  • The prevalence of orofacial pain increases with age, leading to diverse and often complex sources of pain that require comprehensive assessment and management.

Treatment Considerations

  • The attitude and compliance of the patient towards treatment are critical factors that can influence outcomes.

  • It is essential to consider concurrent diseases, potential risks associated with medications, and the financial constraints that may affect treatment options.

Treatment Aids

  • Suggestions for enhancing oral hygiene in elderly patients include the use of modified toothbrushes, electric toothbrushes, and flossettes which cater to their unique needs.

Summary

  • There is a growing elderly population actively returning to dentition management and expressing concerns about oral health and appearance.

  • A holistic approach that addresses both physiological and psychological aspects of care is essential in treating the ageing dentition, ensuring a comprehensive and effective treatment strategy.

Additional Reading

  • Suggested literature includes texts focused on oral histology, gerodontology, and evolving practices in elderly dental care.