Chapter 4

Ageing and Periodontal Disease

Aims

This chapter aims to give the practitioner an insight into the issues involved in managing older patients with periodontal diseases. It covers:

• The frequency with which periodontal diseases are seen in the older population.

• The biological age changes that take place in the periodontium.

• The older patient’s attitude to periodontal diseases.

• How these factors interrelate in the clinical management of periodontal disease in older patients.

Outcomes

Having read this chapter the practitioner should understand what age changes take place in the periodontal tissues, and how these relate to the management of such patients.

Introduction

As outlined in Chapter 1, increases in life expectancy, patient expectations, and the longevity of the natural dentition are likely to place increasing demands on practitioners for periodontal therapy. It is important to have a sound knowledge of the biology of ageing in relation to the periodontal tissues in order to achieve tooth retention for longer and thus facilitate more-effective restorative treatment plans. This chapter outlines the key biological effects on the periodontal tissues and summarises their impact on clinical management in practice.

How Big is the Problem?

With regard to periodontal disease the most recent adult dental health survey published in the UK (1998) reported that patients over 65 years showed the highest incidence of loss of attachment, with 38% of patients over the age of 65 experiencing attachment loss of over 5.5mm. This compares with an average incidence for all dentate subjects of 10%. It is, however, important to recognise that this loss of attachment is due to the cumulative effects of disease progression over a period of time, rather than being a consequence of the ageing process. (This is an important point, which will be discussed later in this chapter.)

The Range of Age Changes Seen in the Periodontium

Extensive research over a number of years has identified a number of changes that are commonly observed in the periodontium with increasing age. When discussing the periodontal tissues it should be remembered this includes the gingival tissues (epithelium and connective tissue), cementum, alveolar bone as well as the periodontal ligament. These tissues, and how ageing alters them, will now be discussed in more detail.

The Gingival Tissues

The gingival tissues comprise both epithelial and connective tissues.

Epithelium

A number of research groups have demonstrated that the epithelial tissues become thinner with age, and this is accompanied by a reduction in the degree of keratinisation of the epithelial tissue. A more controversial finding relates to the rate of turnover of the gingival epithelium. Research in this area has produced inconsistent findings, with some groups noting a reduction in turnover rate while others have found no change or even an increase in cell proliferation. Clinically, the gingivae do appear to become less stippled, but the clinical relevance of this is as yet uncertain.

Connective tissue

With regard to the underlying connective tissue of the gingivae, the main age-related features are a reduction in cellularity, along with a change in texture from a fine to a dense and coarser connective tissue. Researchers have also proposed that the rate of collagen synthesis reduces with increasing age.

These findings may affect how the gingivae respond to periodontal disease progression or indeed therapy, but to date there is no convincing evidence that these histological findings have any direct clinical implications.

Cementum

Cementum is laid down on the root surface throughout life and a number of studies have found that the thickness of cementum increases with age. This is true for the whole root surface but is found to be more pronounced in the apical third region, possibly as a response to passive eruption of the dentition.

The Periodontal Ligament

The periodontal ligament consists of cells, fibres and ground substance, all of which show histological age-related changes. Periodontal fibroblast proliferation, along with collagen and protein synthesis, is reduced, resulting in a less-cellular periodontal ligament. A number of research groups have noted a difference in the width of the periodontal ligament with an increase in age but this has subsequently been related to occlusal loading of teeth rather than being an age change per se.

Alveolar Bone

A number of changes have been demonstrated within alveolar bone. These include a reduction in cellularity, a reduction in the thickness of the cribi-form plate, as well as the surface of the alveolar bone in contact with the periodontal ligament becoming “jagged”, with a less regular insertion of collagen fibres.

Age-related Changes to Dental Plaque

Both quantitative and qualitative microbiological changes have been observed with increasing age. For example, the number of viable microorganisms reduces with age; the number of spirochetes increases, and a reduction in streptococci has also been reported. Other age-related changes in the structure and function of dental plaque have been observed:

• An increase in rate of plaque accumulation and formation.

• Increases in immunological factors (e.g. IgA, IgM, complement component C3, lysozyme) have been demonstrated in plaque harvested from older patients.

These factors are interesting but their importance in terms of susceptibility to, and the natural history of, periodontal disease has yet to be determined.

Immune Response Within the Periodontal Tissues

Another area of interest is the manner in which age impinges on the host’s ability to respond to disease, and in this case, periodontal disease. Extensive research has been published examining how the immune system changes with age. In periodontal diseases this may have an impact on the host’s response to a microbial challenge with periodontal pathogens, which may affect the natural history of the periodontal disease process. It has been proposed by several authors that the immune response is reduced in older patients, and this may result in an increase in susceptibility to a number of diseases including periodontal disease.

Healing Capacity of the Periodontium

There has been extensive literature published on healing responses and increasing age, with the majority of authors concluding that healing is compromised in older subjects. However, clinical studies of patients with periodontal disease seem to show that/>

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