As we age and grow older, our mouth ages and changes as well. There are some clinical signs we can observe in the older population’s mouth and use these observations to determine our patient’s current state of health.
First, the perikymata in the teeth are lost. Perikymata are also known as the imbrication lines that form from the transverse ridges in our teeth during formation. As these line are lost, our tooth appearance changes color due to the way the light is reflected off the surface differently. This also causes the enamel to become more brittle and more susceptible to caries due to an increase of nitrogen in the enamel. Root caries and coronal caries are common in the older population. Over time, roots can become more exposed leaving them prone to caries. Maxillary root caries are evenly distributed due to the large salivary glands close by. Coronal caries don’t necessarily decrease, but because many geriatrics have few premolars and molars left in their mouth it would appear to be the case. Larger restorations, such as crowns, are more common among the elderly due to wear and fractures, not the decay alone (Bori et al., 2016).
Dentin in the teeth also change with age. Smaller pulp chambers can arise due to the fact secondary dentin fills in the chambers as we age. Dentin Sclerosis is when the dentin takes on a translucent appearance because of the calcified dentinal tubules due to an injury or aging. Because the blood supply is reduced and both unmyelinated and myelinated nerves are lost, the tooth has a hard time repairing itself (Bori et al., 2016).
With age, the tongue will lose filiform papilla making it look like it has a smoother appearance. Because more than 50% of the older population is edentulous, many have appliances both fixed and removable. The appliances can change the appearance of the oral cavity. The oral cavity will have lost its stippling and elasticity. The connective tissue and epithelium is what protects the oral cavity. When you age, these protective barriers are lost allowing bacteria to stay in the oral cavity. Chlorhexidine can be used because it is a broad spectrum drug that can kill all the harmful bacteria in the mouth (Bori et al., 2016).
The salivary glands serve many difference purposes in the mouth and can also change over time. They are important in keeping our mouth pH neutral at 7.0. The roots will begin to dissolve if the pH drops just a few digits below 7.0. Proteins and mucins in the saliva help keep the oral cavity protected and lubricated from the harsh chemicals and physical injuries. The lubricant also helps with speech, taste, and swallowing (Bori et al., 2016).
Many patients who complain of a dry mouth need to be assessed to determine if their dry mouth is coming from medications, radiation therapy, systemic diseases, or other behavioral/local factors. Other risk factors that can contribute to dry mouth or reduced saliva flow could include: Sjogren’s Disease, Rheumatoid arthritis, HIV, diabetes, Alzheimer’s disease, dehydration, or strokes. 95% of patients age 50 and older who undergo head and neck radiation acquire permanent salivary hypofunction and xerostomia. Medications inhibit the production of saliva by affecting the transport from acinar cells. Chemotherapeutic agents can decrease saliva secretion. However, once chemo treatment is over saliva secretion will return to normal. Radioactive iodine only causes thyroid tumor issues in the parotid gland. Head and neck radiation can reduce salivary output by 60-90% and it is not a recoverable issue. Signs and symptoms of xerostomia include thick saliva, dry and sticky mouth and lips, mouth and lip sores, difficulty in talking and eating spicy food, increased thirst, and altered taste. Any other dryness outside of the mouth, such as eyes or skin, or even constipation can also be a sign of xerostomia (Bori et al., 2016).
To help treat a patient with xerostomia we can encourage the patient to sip on water or ice chips periodically throughout the day, avoid caffeine and alcohol (even in mouthwash), avoid dry and spicy foods, avoid smoking or using tobacco, use a cold air humidifier, or use a water-based chapstick. Some studies have also shown that powered toothbrushes help to stimulate salivary flow. Khechari mudra is a form of yoga that claims to help increase salivary flow as well. However, one treatment will not be suitable for every patient, each must be individualized (Bori et al., 2016).
Artificial saliva can be used to help with the symptoms of dry mouth. It is important to remember that artificial saliva is not a substitute for our natural saliva but rather a palliative action we can take. Because artificial saliva does not have digestive or antibacterial enzymes in it, the health of the oral cavity is still compromised. Medications that are used to treat salivary hypofunction and/or xerostomia act on the parasympathetic nervous system to alleviate symptoms, such as prilocarpine. A couple ways to manage xerostomia is to rinse with a .12% solution once a day for one week every month for a year. Additional fluoride therapy may be needed to help fight the bacterial infections that can occur in the mouth. Xylitol is a natural sugar that can deprive the bacteria and interfere its growth in the mouth. Silver Diamine Fluoride is effective at arresting active lesions and preventing new caries. SDF also fights against a cariogenic biofilm of S. mutans and Actinomycesnaeslundii (Bori et al., 2016).
When completing OHE with our geriatric patients, it is important to remind them that daily oral hygiene habits are very important. Tobacco cessation should also be addressed and educated on if that is an issue with your patient. This is because tobacco dries out the mouth and for those with an already compromised salivary flow, a bigger impact on the periodontium is often seen. During our appointments, Vaseline can be applied onto the patient's lips to prevent further dryness or cracking, as well as using caution when pulling the patient's cheek or lips. If the patient needs it, allow them to get frequent drinks of water or use the air/water syringe often. We can also encourage the patient to breathe through their nose rather than their mouth to prevent further dryness (Bori et al., 2016).
Bori, M., Clawson, C., Miller, E., Nore, R., Post, M., Schofield, S. (2016). Changes in Teeth and Salivary Glands [PowerPoint slides]. Retrieved lecture notes online web site: http://green.denhalter.com