When treating any patient, but in particular, one who is elderly, it is necessary to consider the needs of the whole person. Management of the elderly requires more than just carrying out repair work to dental tissues which have broken down as a result of aging. Elderly people have special needs, which are partly due to the biological effects of aging, but equally due to a series of social and behavioral changes in their life. This chapter cannot do justice to these aspects of aging but is important to be aware of them. The dentist/therapist must be sensitive to the influence these age changes might have on the resilience of the patient. Treatment must therefore take account of each patient’s needs and be personalized and appropriate.
For example, expensive procedures, which involve long chair-side hours, are not suitable for a pensioner who tires easily and finds it difficult to use public transport. The approach to the elderly patients must take account of their need to retain their personal dignity and respect. They do not want to be hurried or talked at; of all age groups they are least likely to tolerate being persuaded against their will.
Some aspects of biological age changes in the dental hard tissues are unique to the oral environment, but mostly, aging of the structures of the oral cavity occurs just as they do elsewhere in the body. Some of these age changes can be accounted for by a reduction in the rate of cell metabolism. Thus, a reduced mitotic rate causes thin epithelia and slow repair; a reduced cell synthesis causes less bone, saliva, collagen to be produced; a reduction in cell contraction ability causes muscle weakness. These events affect the whole system (e.g., poor circulation, reduced hormone secretions) and they also affect the local oral tissues (e.g., causing thin atrophic mucosa, alveolar bone loss, poor healing). So, changes in the oral cavity occur in association with general biological events of aging; they are not necessarily related to the chronological age of the patient. However, changes in the teeth are a useful (and almost indestructible) guide to the age of an individual and are important for forensic purposes (▶ Fig. 11.1).
Fig. 11.1 A diagrammatic representation of age changes in the teeth. Wear of the enamel causes dentin to be exposed. The pulp chamber has been largely replaced with secondary dentin, and there is narrowing or complete obliteration of the root canal. Loss of epithelial attachment has resulted in a periodontal pocket with epithelial migration down the root face. Loss of alveolar bone height has occurred. The dentinal tubules in the root dentin have become filled with peritubular dentin giving the root dentin a translucent appearance know as sclerotic dentin. Cementum has been deposited around the apex of the root.
Aging is associated with a progressive loss of the teeth. The life expectancy of the dentition varies all over the world, and is not, as one might expect, always related to the level of social welfare. The percentages of edentulous individuals are falling in many developed nations. In the United States, it decreased from 54% who were edentulous in the age group of over 65 years of age in 1960 to 14% edentulous in the same age group in 2010.1 In poorer nations, whose populace has limited access to dental treatment, the percentage of edentulous individuals is higher than in the United States.
Loss of teeth in the elderly used to be thought to be mainly due to periodontal disease, though this assumption has been recently challenged. Where dental services are rudimentary, or unaffordable, dental caries, which goes unrepaired, takes a greater toll. Partial loss of the dentition may increase the risk of further tooth loss, as it imposes a greater strain on the periodontium of the remaining teeth.
Generalized tooth abrasion is a feature of a course diet and has not been seen in Europe since steel was used instead of stone to mill flour. Stone-milled flour contains stone dust which is highly abrasive and gives the bread an unpleasant gritty quality. Attrition is not always related to aging but may be seen on the few remaining teeth of a reduced dentition. The vertical facial height may become reduced if wear is rapid, but it is more common for the facial height to increase with age, as eruption continues without equivalent wear.
Enamel becomes more translucent with age and allows the underlying yellow-colored dentin to be more visible. The enamel also tends to develop cracks which may cause incisal edges to chip off the teeth. The cracks also harbor stains, particularly from tea and tobacco. If enamel has been worn away, as happens on the tips of the lower incisors, the exposed dentin usually becomes darkly stained. These oval-shaped stains are also prominent in the lower incisors of a horse and are known as “marks.” The number of incisors with “marks” is used as an indication of the horse’s age.
The deposition of secondary dentin increases the thickness of dentin over the pulp causing the teeth to be less sensitive. The size of the pulp chamber and the diameter of the root canal are reduced, and this may cause difficulty during endodontic treatment. While secondary dentin is a feature of old age, it is also seen in younger patients as a response to caries and attrition. Peritubular deposits of calcified tissue cause the dentin to become less porous and more brittle, which may lead to fracture. This sclerotic dentin begins at the apical part of the root and spreads coronally with age. The increasingly brittle nature of root dentin of the elderly patient may lead to root fracture during extraction of the tooth, should this be necessary.
The pulp becomes less cellular and more fibrous. This may be related to the decrease in vascular supply, reduced metabolism, and slower turnover of collagen. The reduced pulp metabolism reduces its capacity for recovery from inflammation and repair of pulp exposures. Intracellular vacuoles are found within the odontoblasts, and large extracellular vacuoles can be seen throughout the pulp tissue of elderly individuals.
In elderly individuals, who have not suffered from periodontal disease, the teeth may show some wear and be firmly attached to alveolar bone with a narrow periodontal space. In many individuals, there would be some degree of gingival recession with root exposure and mobility, giving rise to the expression “long in the tooth.” The junctional epithelium migrates progressively apically with age.