Geriatric Periodontology?—The Periodontium in the Elderly
Different Circumstances—Modified Concepts of Treatment
The percentage of elderly individuals within the entire population continues to increase, but differences exist between the “Third World” and the industrialized nations (Fig. 726).
Problem 1 for dentistry and dental hygiene is the increasingly wide chasm between that which is absolutely necessary and that which is possible. This intriguing development brings with it socioeconomic considerations, technical health insurance matters and medical-ethical dilemmas, the magnitude of which has only been recognized in recent years.
The World Health Organization categorizes our aging population in four classes:
Aging individuals 45–60 years old
Older individuals 61–75 years old
Old individuals 76–90 years old
Very old individuals 91–100 years old
It is clear, of course, that the overall state of health of individual persons cannot be considered solely on the basis of age. Much more than age, each individual’s physical, psychic and spectral conditions are most meaningful for individual quality of life. Diseases and the medications used to treat them may therefore prejudge dental treatment planning (ASA classification, medical history; p. 212).
Despite the increasing number of elderly persons, fewer complete dentures are fabricated today compared to earlier decades. This is likely due to enhanced knowledge of the etiology and pathogenesis of dental and periodontal structures in the second half of the twentieth century, which has increased enormously. This knowledge has led to comprehensive and intensive prophylaxis, which continues its effectiveness even into old age.
In addition, dental treatment techniques and preventive strategies have continued to develop and to be refined, so that a significantly extended maintenance of the natural teeth is virtually guaranteed.
Different Circumstances—Different Prerequisites
The population’s development toward ever more elderly individuals in industrialized nations obviously has a substantial effect in the dental specialty of periodontics, and the practice of dental hygiene.
In the chapter Therapy (p. 201), it was noted that for the treatment of gingivitis, periodontitis and gingival recession, scientifically validated therapeutic concepts now exist.
However, with the massive changes in the age distribution of the population, such concepts must be revisited.
Elderly individuals endure somatic and psychic changes, which may force the physician and the dentist to deviate from normal and usual treatment concepts. But this fact must never signify that our elderly and possibly also medically compromised patients should be “poorly” treated; rather, the significance is that these patients must simply be treated differently than young and medically healthy individuals.
It is important to note that the aging process does not necessarily reduce all physical and psychic functions and coordinations (Geering 1986):
Capabilities that remain or may even be enhanced:
Ability to learn
Psychic and physical capabilities
Self-satisfaction, compassion, kindness etc., but also the stubbornness of age
On the other hand, certain capacities and functions are reduced in the elderly:
Immune response is reduced, and the danger of infection increases
Systemic diseases and the ingestion of medicaments increases
The regenerative capacity of tissues is reduced, also in the oral cavity
Physical capabilities are reduced
Oral hygiene is often neglected
Root surface caries increases
Structural/Biological Changes in the Periodontal Tissues of Elderly Individuals
In addition to the above-discussed factors that apply to the entire organism, there are also completely normal clinical and structural biological aging processes in all organs and tissues, which can also be recognized in the periodontium. The chapter “Gingival Recession” (p. 155) described recession-like clinical appearances in elderly persons. Fig. 728 depicts the clinical appearance of an old yet periodontally “healthy” man. The gingival recession/shrinkage—also inter-dentally—can be explained by external influences over many decades: Mild but chronic inflammation results in “shrinkage” of the gingiva and this is enhanced by improper oral hygiene and possible iatrogenic irritation.
Of significance for the periodontium are structural and biological aging processes of the gingiva (epithelium and connective tissue), the periodontal ligament and the alveolar bone. Healing, i.e., regenerative processes, appear to be less effective with increasing age (e.g., reduced quantity of precursor (stem) cells.
Changes in the gingival epithelium are directed for the most part by the subepithelial connective tissue. For the proliferation, and therewith the turnover of the epithelium, there are varying explanations: While some authors have described an increase in proliferative activity with age, others report stationary proliferation or even a decrease. Irregardless of these reports, there is consensus that the oral mucosa and also the gingiva becomes thinner, “softer,” and drier (reduced saliva production) and there is a loss of gingival stippling. In elderly individuals, all mucosal surfaces are more susceptible to mechanical irritation in comparison to younger persons. Histologically, there is a reduction of keratinization of the gingiva, as well as atrophy in the region of the Stratum spinosum. All of these alterations are more common in females during menopause than in males of equal age, and may be explained by the reduction in ovarian function.
Research studies have not demonstrated any deviation from normal structural relationships in the junctional epithelium with age.
Age-related connective tissue changes can be observed in the gingiva as well as in the periodontal ligament. The number of fibroblasts (and their mitotic activity) is reduced, as is collagen synthesis. The collagen within the periodontal ligament exhibits normal distribution, but the fiber bundles are thicker and more dense. Simultaneously, the organic matrix is reduced. Hyaline zones may form, and these (seldom) lead to cartilage-like or calcified regeneration. The number of Malassez epithelial rest cells becomes diminished.
The thickness of the cellular mixed-fiber cementum increases, especially in the apical third of the root surface and in furcations areas.
The periodontal ligament space becomes narrower, but this may also be the result of functional forces (afunction, hypo-function).
Vessels may exhibit atherosclerotic alterations, and vascularization generally is reduced.
In elderly persons, osteoporotic changes in bone—resorption of compact bone and expansion of the marrow spaces—can also affect the jaw bones, but in this intra-oral localization, these lytic processes play a less significant role than was previously assumed. Osteoporosis is much more often observed in the long bones and vertebral column. Females, because of the reduction in estrogen production, are more often affected than males; women should be regularly tested following menopause (bone thickness/density measurements).
The question has often been raised whether with elderly patients periodontal procedures, especially surgical interventions, are at all indicated, or whether disturbances of wound healing are to be expected, leading to failure. This perceived danger is unsubstantiated. Even though in elderly patients fewer stem cells are present in all tissues, their potency remains unaltered. The single problem is the temporal sequence of biologic events leading to complete healing: This process can be significantly longer than in young individuals.
Age-related Changes—Influence Upon Treatment Planning
In this Atlas, we have repeatedly stated that certain prerequisites must be fulfilled before initiation of comprehensive periodontitis treatment:
Time, understanding and resiliency of the patient
Persistent and appropriate compliance with regard to oral hygiene
Good general systemic health
Reduction of risk factors
Even in elderly individuals, these prerequisites can surely also remain, if the patient is psychologically and physically healthy. Particularly, the elderly today often demand optimum treatment, similar to that offered to younger patients. These older patients seek no compromises in their treatment, simply because they are old! They often do not even want to compromise when it comes to oral esthetics.
On the other hand, some elderly patients will not fulfill the above-listed criteria for periodontal therapy, or fulfill them only partially. Their reduced capacities (“it is no longer worth it”!) must often lead to therapeutic compromises. In many cases, the mental capacity/understanding for systematic treatment is lacking. Only the “most necessary” or pain-alleviating treatment should be performed: The patient, in her/his age-related inflexibility, often knows better what to do—or what not to do—than the dental team itself.
Also severe systemic diseases such as diabetes, Alzheimer’s, tumors, autoimmune disease, Parkinson’s, hematologic disorders, and medication side effects must influence the oral/dental treatment plan significantly.
In general, manual dexterity decreases with age. Elderly patients with diseases such as those listed above may often not understand the importance of oral hygiene, or may be incapable of performing it. It is not always possible to replace the manual toothbrush with an electric device or by medicinal oral rinsing (CHX; cf. p. 235). The result is often greater plaque accumulation, and as a result, gingivitis and even periodontitis. Statistical studies have demonstrated that periodontal diseases develop more rapidly and more severely in the elderly as compared to young persons (Imfeld 1985). Nevertheless, periodontitis can no longer be categorized as a “disease of aging.”
In addition to the previously discussed systemic health problems and oral hygiene difficulties of elderly patients, the dentition will also exhibit manifestations of age such as attrition, abrasion, gingival recession and tooth discoloration.
Modified Treatment Planning
Old but still mentally and physically healthy patients usually do not require any changes in dental treatment planning. However, in patients who are mentally and/or physically handicapped, the treatment plan must be adapted to the actual situation. Teeth with a questionable prognosis should probably be extracted. A perhaps somewhat extreme approach would be to treat periodontally only those teeth that can be expected to be maintained until life’s end.
Missing teeth in non-visible jaw segments beg the question of whether replacement is necessary. If replacement is unavoidable for functional reasons, a removable partial denture is often preferable to a fixed reconstruction.
It is better to incorporate a dental prosthesis at an age at which the patient can become accustomed to it, instead of persisting with years-long (decades-long) periodontal therapy, leading finally only to a complete denture that the patient can no longer successfully accept.
Teeth need not be maintained “at all costs” in elderly patients; rather it is the sense of oral well-being (health, function, phonetics, esthetics) and therewith the patient’s own feeling of self worth.