AGEING AND ITS EFFECT ON DENTURE BEARING AREA

Presented by: Dr. Binita Pathak 1st year Resident Department of Prosthodontics and Maxillofacial Prosthetics Peoples Dental College and Hospital, Nayabazaar

CONTENTS

INTRODUCTION

DIFFERENT TERMINOLOGIES

MYTHS AND FACTS

THEORIES OF AGEING

GENERAL CHANGES

ORAL CHANGES

CHANGES ON DENTURE BEARING AREA

CONCLUSION

REFERENCES

INTRODUCTION:
Ageing is a complex biological process in which changes at molecular, cellular and organ levels result in a progressive, inevitable, and inescapable decrease in the body's ability to respond appropriately to internal and/or external stressors. Chodzko-Zajko & Ringel, 1987 Ageing is not a disease. It is the process of growing old or maturing. It occurs at different rates among individuals and within individuals. It does not generally cause symptoms, but our bodys changes make us vulnerable to some medical conditions. Ageing is not a simple process. As adults grow older, physical, emotional ,psychological, and social changes occur. The rate at which these changes occur and how they impact an individual is based on a number of factors-genetics, environment, health, stress, and diet all contribute to the manner in which a person ages.

DIFFERENT TERMINOLOGIES
GERIATRICS - The study of diseases that affect the ageing population and medical care of older persons.

GERONTOLOGY- Study of ageing in all its aspects biologic ,physiologic ,sociologic & psychologic. - PEDERSON & LOE It is the science that deals with process of ageing.

GERODONTOLOGY- It is the branch of dentistry that deals with the oral health problems of the old people.

HEALTHY AGEING - According to Ryff and Singer, corresponding to biological and behavioral/ medical orientations: (a) fending off cellular and molecular damage for the longest possible period of the life course (b) the maximal delay of illness, disease disability and hence mortalityfactors that keep the organism functioning optimally for the longest period of time.

SUCCESSFUL AGEINGSix dimensions of successful ageing 1. No physical disability over the age of 75 as rated by physician. 2. Good subjective health assessment . i.e good self rating of ones health 3. Length of undisabled life 4. Good mental health 5. Objective social support
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6. Self rated life satisfaction in different domains of life eg. marriage., income, religion, hobbies etc

LIFESPAN
Life is often divided into various age ranges-

1. Juvenile(via infancy, childhood, pre-adolescence , adolescence): 0-19 yrs 2. Early adulthood : 20-39 yrs 3. Middle adulthood : 40-59 yrs 4. Late adulthood: 60+

Term

Age(years)

Newborn Infant Toddler Preschooler Child/kid Pre-Teenager Teenager Vicenarian

Birth to 1 month 0-1 1-2 3-4 5-9 10-12 13-19 20-29

Tricenarian Quadragenarian Quinquagenarian Sexagenarian Septuagenarian Octogenarian Nonagenarian Centenarian Supercentenarian

30-39 40-49 50-59 60-69 70-79 80-89 90-99 100-109 110 and older

Ageing patients fits into one of three groups 1. Those who are well preserved physically and emotionally 2. Those who are really aged and chronically ill 3. Those who fall between the two extremes

Spirgi (1975) and Breustedt (1978) divide elderly into three groups according to their psychologic characteristics:

Conservative attitude These people deny any age related limitations. They feel threatened by any type of prosthesis, which they regard as evidence of their physical decline.
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Indifferent They react with resignation to specific changes associated with ageing They make no efforts to adapt or to prepare themselves for difficulties of old age

Attempts master old age They are well informed about the changes of ageing they face and have intellectual understanding and are ready to cooperate But are emotional.

MYTHS ABOUT AGEING

MYTH Our physiological process remains at a constant level of efficiency until we approach old age , at which they undergo a drastic decline Must adult proceed at much the same rate through the series of similar physical changes Most adult past 65 are so physically incapacitated that they must depend to a great extent on other people

BEST AVAILABLE EVIDENCE Most of our bodily functions reach their maximum capacity prior to or during early adulthood and begin a gradual decline thereafter Age related physical changes do not occur according to strict timetable. Adults ages at different rates. Helplessness and dependency are not characteristics of old age. 87% of adult over 65 are able to cope more than adequately with demands of everyday living

Taking large dose of antioxidants will extend the length of life

There are no drugs , pills , vitamin, dietary supplements with proven anti aging capacities.

TYPES OF AGEING:
ENVIRONMENTAL AGEING It is an extrinsic process and is the result of harmful exterior factors accelerating ageing signs and symptoms.The exterior factors are environmental factors such as sun radiation ,pollution , stress.

HORMONAL AGEING Ii is specifically associated with changes in hormone levels.This ageing starts earlier or later depending on hormonal production and fluctuation.

GENETIC AGEING It is dictated by our genetic makeup.The process is natural and continuous one and nobody can prevent or run away from it.

THEORIES OF AGEING
PROGRAMMED SENESCENCE, OR AGING CLOCK THEORY. The aging of the cells of each individual is programmed into the genes, and it determines the life expectancy of cells of body and therefore ,the whole body.When cells die at a rate faster than they are replaced, organs do not function properly, and they are soon unable to maintain the functions necessary for life. GENETIC THEORY. The genetic factors are important determinants for ageing.Human cells maintain their own seed of destruction at the level of the chromosomes.

CONNECTIVE TISSUE, OR CROSS-LINKING THEORY. Changes in the make-up of the connective tissue alter the stability of body structures, causing a loss of elasticity and functioning, and leading to symptoms of aging.

FREE-RADICAL THEORY. The most commonly held theory of ageing.It proposes that there is progressive accumulation of high energy oxygen species that progressively and irreversibly damages cellular components, this accumulated damage leads to ageing.
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IMMUNOLOGICAL THEORY OR WEAR OR TEAR THEORY There are changes in the immune system as it begins to wear out, and the body is more prone to infections and tissue damage, which may finally cause death.Also, as the system breaks down, the body is more apt to have autoimmune reactions, in which the body's own cells are mistaken for foreign material and are destroyed or damaged by the immune system.

Erik Erikson proposes two major theories to explain the psychosocial aspects of ageing in older adults.

DISENGAGEMENT THEORY This theory views ageing as a process of mutual withdrawal in which older adults voluntarily slow down by retiring, as expected by society. Proponents of disengagement theory hold that mutual social withdrawal benefits both individuals and society.

ACTIVITY THEORY On the other hand, this theory sees a positive correlation between keeping active and ageing well. Proponents of activity theory hold that mutual social withdrawal runs counter to traditional American ideals of activity, energy, and industry.In other words, growing old means different things for different people. Individuals who led active lives as young and middle adults will probably remain active as older adults, while those who were less active may become more disengaged as they age.

CHANGES SEEN WITH AGEING

A. PHYSIOLOGIC CHANGES

CHANGES SEEN IN RESPIRATORY SYSTEM The lungs become stiffer.Chest wall becomes more rigid. Total lung capacity remains constant but vital capacity decreases and residual volume increases. The alveolar surface area decreases by up to 20 percent. Alveoli tend to collapse sooner on expiration. Increased mucus production and a decreased activity and number of cilia.

CHANGES SEEN IN CARDIOVASCULAR SYSTEM Cardiac muscle becomes slightly stiffer and may increase slightly in size. Despite this slight increase in heart size, the amount of blood the chamber can hold may actually decrease because the heart wall thickens.Aorta and other arteries becomes thicker and stiffer which bring a moderate increase in systolic blood pressure, increase afterload of heart.Cardiac output decreases linearly.

CHANGES SEEN IN GASTROINTESTINAL SYSTEM Increased prevalence of atrophic gastritis and achlorhydria,The liver is less efficient in metabolizing drugs and repairing damaged liver cells.Reduced peristalsis of the colon can increase risk for constipation. Intestines do not change significantly in their ability to absorb foods as well as drugs,but absorbs less calcium,enzymes, such as lactase which aids the digestion of lactose (a sugar found in products) decline with age.

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CHANGES SEEN IN MUSCULOSKELETAL SYSTEM There is loss of muscle strength and coordination, with an accompanying loss of mobility, agility, and flexibility.Also decrease in bone strength and density making it more brittle. As age advances there is reduction in protein formation leading to shrinkage in muscle mass and decreased bone formation, possibly leading to osteoporosis.Body fat mass can double, lean muscle mass is lost. Weight increases until about age 60 and then declines.

CHANGES SEEN IN ENDOCRINE SYSTEM Hormone levels gradually decline. The thyroid and sexual hormones are particularly affected.Peripheral Insulin resistance and abnormal beta cell function leads to increased glucose intolerance.Decrease in aldosterone and cortisol may affect immune and cardiovascular function.

The thyroid hormone affects the rate of metabolism of cells in general and hence the activity of both, the osteoblasts and osteoclasts. Parathyroid hormone influences the excretion of phosphorous in the kidney and also directly influences osteoclasts Estrogen prevent osteoporosis by inhibiting the stimulatory effects of certain cytokines on osteoclasts also it protects bone from effects of parathyroid hormone In a young person: Anabolic hormones (estrogen and testosterone) > antianabolic hormones (cortisone and hydrocortisone) =continued growth of skeleton

In older population: anabolic hormones < antianabolic hormones in relative excess =bone resorption,bone mass may be reduced

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CHANGES SEEN IN UROGENITAL SYSTEM Kidney mass decreases by 25-30 percent and the number of glomeruli decrease by 30 to 40%.There is a reduced hormonal response (vasopressin) and an impaired ability to conserve salt which increase risk for dehydration. Tubular function decreases.Estrogen levels drop by 95% and Testosterone levels drop by up to 35%.

CHANGES SEEN IN IMMUNE SYSTEM Decreased levels of antibody and antigens response.T and B Cell related immunity becomes impaired and results diminished ability to fight off acute infection.

CHANGES SEEN IN SENSORY SYSTEM Reduced Lens Elasticity (Presbyopia) loss of ability to see close objects or small print. A decrease in the sensations of taste and smell Presbycusis- age-related hearing loss, Reduced sensitivity to heat

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CHANGES SEEN IN NEUROLOGICAL SYSTEM Intellectual ability are slowly diminished.Speed of memory recall decreases sharply. There are age related changes in neurotransmitters, resulting in motor dysfunction. Sensory perception sharply declines due to decreased neuronal function which leads to Decreased pain perception Decreased sympathetic tone Loss of muscle tone Diminished proprioception Decreased coordination Balance problems

CHANGES SEEN IN SKIN Skin becomes thin, wrinkled and dried, loses fat, so it looks less plump and smooth. Nasolabial groove deepens, which produces sagging look to middle third of face.Atrophy of subcutaneous buccal pad of fat hollows the cheek. Decreased sweating leading to dry Skin The skin feels rough and scaly and often is accompanied by a distressing, intense itchiness.The loss of sweat and oil glands may worsen dry skin. Epidermis -Atrophy most pronounced in exposed areas like face, neck, extensor surface of hands, forearms. Thinning of epidermis. Notable flattening of dermo-epidermal junction Turnover rate of cells in stratum corneum decreases. Dermis -Dermal collagen becomes stiffer and less pliable.Elastin is more cross linked with high degree of calcification. This causes skin to loose tone and elasticity resulting in sagging and wrinkling.There is decrease in number of dermal blood vessels.

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B.

PSYCHOLOGIC CHANGES
Mental functioning deteriorates- During the younger years, mental prowess, including math and verbal skills, increase over time until a person reaches 50 years of age. These skills then stabilize between the ages of 50 and 60 Impairment in decision making.Memory loss-Affects short term memory Absent mindedness,Clear lucid thoughts become difficult Repetition of conversation within themselves. A major psychological problem seen in the elderly is depression. With aging, the bodys physical state can deteriorate, making independence and self support increasingly difficult. With the onset of debilitating conditions, depression can worsen, increasing the possibility of suicide.

C.

NUTRITIONAL CHANGES WITH AGEING

Factors responsible for poor nutrition of elderly areTooth loss, muscle weakness, poor coordination make difficult to chew properly Reduction in number of taste buds and decrease in taste perception Diminished tactile sensation reduces efficiency in food management and control Reduction in saliva production reduces protection of mucosa Economic condition

AGE CHANGES IN MASTICATORY SYSTEM

CHANGES IN TEETH :Changes in the teeth are a useful(and almost indestructible) guide to the
age of an individual and are important for forensic purposes. Ageing is associated with a progressive loss of the teeth. Abrasion and attrition present.The vertical facial height may get shorter if wear is rapid, but it is more common for the face to get longer with age, as eruption continues without equivalent wear. Stains and discoloration seen because enamel becomes more translucent with age and allows the underlying yellow
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dentine to be more visible. The enamel also tends to develop cracks which may cause edges to chip off the teeth. The cracks also harbor stains, particularly from black tea and tobacco..

Secondary and sclerotic dentine deposits present. The deposition of secondary dentine increases the thickness of dentine over the pulp making the teeth less sensitive . The size of the pulp chamber and the diameter of the root canal is reduced and this makes root canal treatment difficult. Peritubular deposits of calcified tissue make dentine less porous and more brittle.

CHANGES IN PULP
Pulp becomes less cellular and more fibrous.This may be related to 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. Intra-cellular vacuoles found within odontoblasts and large extra-cellular vacoules seen in pulp.

CHANGES IN THE TOOTH SUPPORT Periodontal ligament

The teeth may be worn down, and firmly attached with a narrow periodontal space; or they may be gingival recession with root exposure and mobility, giving rise to the expression "long in the tooth". The junctional epithelium migrates progressively apically.

Cementum
Thickness of cementum gradually increases mostly around apical third of tooth and around apex of tooth.The cementum is cellular and shows lines of incrementation. Higher risk of developing root caries due to gingival recession

Alveolar bone
Patients who have lost all their teeth tend to lose the bone of the residual alveolar ridge and this may make it difficult for them to wear dentures. Ageing bone is also characterised by an increase in bone resorption called osteoporosis. This combination of tooth loss and osteoporosis, accentuates the resorption of the residual alveolar ridge.

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CHANGES IN TMJ
Condyle appears flattened in outline,Flattening of articular surface as a result of remodelling of condyle related to wear of teeth.Islands of cartilage and development of clefts in fibrous joint surface and disc. Articular disc become thinner and exhibit hyalinization, may perforate.Walls of blood vessels are thickened,Nerves appear decreased in capsule. Alteration found in synovial folds lead to decrease in formation of synovial fluid Osteoporosis is common,it may become so advanced that ramus and condyle appear to be thin shell of cortical bone. Changes in connective tissue elements in capsule and disc results decrease in their extensibility and result in impaired motion.Chondroid changes to collagenous elements of articular tubercle, articular disc and condyle affect degree of resiliency during masticatory function. Since neuromuscular control is diminished, mandibular movements may be involuntary and less well coordinated.
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CHANGES IN JAW AND JAW MUSCLES

Mandible show certain changes in external features as age advances. At birth mental foramen lies close to lower border of body of mandible,gradually shifts upward and in adult lies in midway between upper and lower border of body and in old age it lies nearer to upper border. Angle of mandible is wide in childhood, becomes more acute in adult and again becomes wide in old age.. E Dubrul and Scott Symons stated that loss of teeth means loss of function, is usually associated with some disuse atrophy of muscle of mastication which leads to wide mandibular angle in old age. Jaw muscles also show some age related changes, Muscle function is dependent on the performance of the nervous system and both exhibit independent age-related changes. Masseter and Medial pterygoid muscles suffer a decrease in cross-sectional area and in muscle density as a consequence of advancing age.The decrease is more apparent in edentulous people (Newton et al. 1993). Reduction of tonicity and muscle activity lacks coordination because motor control loses its precision with age due to the loss of individual motor units and the recruitment of the remaining muscle fibers by neighboring units.Quicker tiring during chewing due to decreased muscle strength and reduction in maximal bite force.

Fig. Muscles attachment changes with progressive bone loss

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CHANGES IN TONGUE Tongue appears smooth and shiny due to atrophy of papilla Sometimes fissured Sublingual varicosities present as deep red bluish nodular dilated vessels on either side of midline on ventral surface and floor of mouth Loses its muscular tonus, without reducing in size

SALIVARY GLAND CHANGES Decrease in salivary flow due to reduction of cell synthesis. Histologic changes in gland Acinar atrophy accompanied by fibrosis Replacement of secretory tissue with adipose tissue Structural alterations in ducts including intraductal deposits Appearance of oncocytes (enlarged ,inactive secretory cell with pycnotic nuclei) arise from acini.

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CHANGES IN DENTURE BEARING AREA

Denture bearing area/ Denture foundation area : The surfaces of the oral structure available to support a denture ; GPT Age brings about some deterioration of the denture-bearing tissues. ORAL MUCOSAL CHANGESEpithelium It becomes thin and less hydrated.There is increase mitosis with slow turnover of cells It loses elasticity and atrophies with age. Connective tissue It is less resilient.There is decrease in cellularity with increase in collagen,decrease vascularity Thinning of mucosa allows fordyces spot to become more evident. Mucosa appear smooth and shiny due to their thinner nature and existence of nutritional deficiency.The ability of the mucosa to heal is impaired.Capillaries are more fragile, therefore petechiae occur frequently. Reduced blood supply to tissues, compromising more cell regeneration and delaying the healing process.Reduced blood influx also leads to cell atrophy ,reducing their hydrous content, tissue gradually lose elasticity and undergo fatty infiltration.Finally making mucosa more susceptible to external stimuli.

Ageing of the oral mucosa has so far been characterized mostly in relation to changes in the oral epithelium such as less prominent rete ridges, decreased mean thickness (Shklar 1966; Scott et al.1983; Williams and Cruchley 1994), decreased cell density (Hill 1988), decreased mitotic activity and consequently a slowdown in tissue regeneration and healing rates (Barakat et al. 1969; Karring and Loe1973; Hill et al. 1994). American Ageing Association 2011

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RESIDUAL RIDGE CHANGES It includes Residual alveolar ridge or bone changes, Jaws become porous with time because of metabolic changes in bone.Osseous tissue become less dense and cortical plates thinner, which reduces the denture bearing ability. Bone mass in all parts of skeleton including jaws decreases with age. This occurs because Osteoblasts are less efficient Estrogen production declines There is overall reduction of calcium absorption from intestine. Effect of tooth loss is always the same: The physiologic masticatory forces applied via the roots of teeth to the cancellous alveolar bone no longer persist. According to Wolffs Law disuse and a loss of mechanical stimulation is followed by the reduction of bone mass.However, loss of teeth leads invariably to atrophy of the residual alveolar ridge being irreversible, chronic, progressive and cumulative(Atwood, 1971)

Classification system of six atrophy stages in the maxilla (A) and the mandible (B)
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6 stages of atrophy described by Atwood (1963) and Cawood and Howell (1988)-

Order 1 - physiological state of preextraction at which the tooth is still in the alveolar socket Order 2 - immediately after tooth loss/postextraction. There are slight osseous reactions of new bone formation within the alveolus. The alveolus is still in a good condition and the edges might be sharpened. Order 3 - the alveolus is completely refilled with newly formed bone. The alveolar process finally becomes well-rounded due to first signs of resorption. However, there is no notable reduction in height. Order 4 - the shape of the alveolar crest alters into a thin and sharp knife-edge; the body of the jaw is still adequate in height and width. Order 5 - Further resorption leads to a low well-rounded ridge which is flat but already reduced in height and width; the alveolar process is lost. Order 6 - Continuing excessive atrophy of the residual crest results in a depressed bone level, where even the basal bone shows signs of reduction.

In posterioir segment atrophy appeared to attain more severe stages more rapidly with increasing age.Fishers exact tests showed a statistically significant relationship between age group and atrophy stage in anterior segments of the mandible.

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CHANGES IN MAXILLA AND MANDIBLE Resorption pattern in the maxilla is upward and inward.Since the tooth is directed downward and outward ,the outer cortical plate is thinner than the inner cortical plate, resorption from the outer cortex tends to be more rapid.Thus the maxillary residual ridge loses height and maxillary arch becomes narrower from side to side and shorter anteroposteriorly.Hence longer the period of edentulism, smaller and narrower the maxilla.As the maxilla becomes smaller in all dimensions, the denture bearing area(basal seat) decreases.

Resorption pattern in mandible is downward and outward.Since anterior teeth is generally inclined upward and forward to the occlusal plane and posterior teeth is inclined vertically or slightly lingually ,the total width of bony foundation of mandibular basal seat becomes wider in molar region.The width of inferior border of mandible from side to side is greater than width of mandible in alveolar process from side to side.The mandible is wider at its inferior border than at the residual alveolar ridge in the posterior part of the mouth, resorption in effect, moves the left and right ridges progressively farther apart.This pattern of resorption results in wider mandible and narrower maxilla and makes the patients profile prognathic.

The reduction in the anterior residual ridge height in the mandible has been determined to be four times the rate of loss found in the maxillae.Atrophy is greatest during the first year after tooth loss; the reduction of the residual ridge is a lifelong process (Sennerby et al., 1988) but the rate of bone loss does decrease (Denissen et al., 1993). Reduced denture bearing area with reduced capacity to bear external stress

Residual ridge resorption is directly proportional to the age of the patient and to the degree of osteoporosis, inversely proportional to dietary Ca intake and is more common in females. Deshpande ss, sarin sp. Evaluation of the relationship between systemic osteoporosis, dietary ca intake and the reduction of residual ridges in an edentulous patient:an in vivo pilot study, Journal of clinical and diagnostic research.2009 Aug; (3) 1706-1709

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OVERALL FACIAL CHANGES SEEN IN ELDERLY Prognathic appearance Thinning of lips Deepening of nasolabial groove Increased depth of associated vertical lines Increase in columella-philtral angle Ptosis of muscles(witchs chin) Decrease in horizontal labial angle at corner of lips

CONCLUSION
Ageing is an inevitable natural process. Geriatrics patients suffer not only from alterations of anatomic structures of their jaw and loss of function, but also from the changes of facial shape and psychological problems . So a treatment plan for an elderly patient should be in a way that it restores function as well as preserve the appearance and well being of patient.

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REFERENCES

Bouchers Prosthodontic Treatment for Edentulous Patients- Twelfth edition Vern L. Bengtson, Merril Silverstein.Hand Book Of Theories of Ageing- 2nd edition Sheldon Winkler.Essentials of complete denture prosthodontics IInd edition. Reed D,Foley D et al. Predictors of healthy aging in men with high life expectancies. American Journal of Public Health;88: 1463-1468. Boss GR, Seeqmiller JE. Changes and their clinical significance in geriatric Medicine.West J Med; 1981 December; 135(6):434-440. Leonard Guarente et al. Trends in Pharmacological Sciences. 11 march 2010; 31(5): 212-220. Atwood DA:Reduction of residual ridges:A major oral disease entity.J Prosthet Dent 1971;26:266-279 Gonsalves W,Henry R,Wrightson et al.Common oral conditions in older person.Am Fam Physician.2008 Oct 1;78(7):845-852. Rajani J,Rajani S.An overview of factors responsible for age changes in edentulous mandible.Journal of dental sciences.2011Mar;2(1) Misch C.Contemporary implant dentistry:Mosby;1993

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