Health Articles

Adequate salivary gland function is essential to all aspects of oral health. Saliva is necessary to form and translocate food boluses, to lubricate and maintain the integrity of the oral mucosa, and to prevent demineralization and promote remineralization of teeth. It contains at least six antimicrobial proteins that control bacterial colonization and limit fungal and viral growth. Saliva buffers acids produced by bacteria and mechanically cleanses the mouth.
Many studies have suggested that salivary gland morphologic appearance is altered in older people, with parallel reductions in saliva production. However, recent studies in carefully defined populations indicate thai no general reduction in salivary performance occurs with age; resting and stimulated parolid gland function remains intact. Reductions in submandibular-sublingual saliva seen in (he well elderly are probably nol biologically significant. Most age-related changes in salivary funclion are attributed to syslemic disorders or their treatment.
Etiology
Salivary gland disorders are usually iatrogenic or caused by Sjogren’s syndrome. Less frequently observed conditions (hat affect salivary glands include bacteria! infections, sialoliths, trauma, and neoplasms.
Iatrogenic: Salivary gland dysfunclion is usually drug related. Xerostomia is a potential side effect of > 400 drugs (see TABLE 52-1), many of which are often used by the elderly. In addilion, head and neck irradiation (in particular) and cytotoxic chemotherapy for neoplasms directly and dramatically affect salivary gland performance.
Sjogren’s syndrome, an autoimmune exocrinopathy afflicting primarily women, is the most common disease affecting salivary glands in older persons. It may occur as a primary disorder (affecting only Ihe salivary and lacrimal glands) or in a secondary form (with glandular dysfunclion and connective tissue disease).
Symptoms and Signs
Xerostomia, dryness of the mouth, is the most common condition linked with salivary dysfunction. It may be associated with reduced salivary output or could result from altered lubricalory factors, defective sensory receptors, or impaired cognition. Patients with true salivary gland dysfunction (ypically have difficulty swallowing dry foods, a need to drink while attempting to swallow, dryness of the mouth and lips while caling, and difficulty in speaking at length. Important signs include an unexpected recent increase in dental caries and ulccraled, erythematous, or furrowed mucosa. However, mucosa may appear normal even when glands are dysfunctional.
Diagnosis
Salivary gland status should first be evaluated by oral examination. Attempts should be made lo assess major gland duct patency and to express saliva from each orifice. Saliva production should be measured quantitatively under basal and stimulated conditions. For evaluation of total saliva flow, patients should be instructed to have nothing by mouth for90min. Ask the patient to swallow any saliva present, then to let saliva passively accumulate in the mouth fora set time (I to 5 min), followed by expectoration in(o a calibrated vessel. The volume per minute is the whole saliva resting flow rale. Stimulated saliva is collected in a similar manner except that saliva production is stimulated with lemon juice or by chewing a rubber band. Typically, basal funclion is severely reduced in affected persons, although many show some stimulated saliva production, indicating the presence of functional gland parenchyma. Absence of stimulated secretions indicates the loss of fluid-secreting cells.
Retrograde sialography is a particularly useful diagnostic imaging method when inflammatory or obstructive disorders are suspected. Sodium pertechnetate Tc 99m scintigraphy is useful when acinar function needs to be assessed objectively. The radionuclide parallels water movement: bolh an uptake phase (which shows acinar parenchyma) and an efflux phase (which shows secretion into the mouth) are clearly visualized.
If Sjogren’s syndrome is suspected, biopsy of minor labial salivary glands should be performed (usually by an oral surgeon* and lacrimal gland function should be evaluated. Additionally, serologic markers of autoimmune disease (particularly anti-SS-A, anti-SS-B. and rheumatoid faclor) should be analyzed.
Clinical features of sialadenitis (salivary gland inflammation) can include fever and swelling, pain, and erythema over the affected gland. When the gland is palpated, a purulent discharge that can be gram-stained and cultured is expressed from the ducts; the most common organism is Staphylococcus aureus.
Treatment
Drug-induced gland dysfunction is almost always fully reversible. If action is warranted because of oral complications, either reducing drug levels or using alternative drugs may help. In patients with basal secretory deficits who have some stimulated responses, pharmacologic stimulation of salivary glands has been achieved with the cholinergic agent pilocarpine 5 mg orally tid. There is no satisfactory treatment for Ihe auloimmune component of gland hypofimclion.
Patients without functional gland parenchyma have no fluid-transporting cells and do not respond to any directed salivary or systemic therapy. They should have frequent, comprehensive, preventive dental care.
Salivary substitutes are helpful in limiting hard tissue problems but unsatisfactory for soft tissue complaints. For the latter, only palliative therapy is available. Mouthwashes, including topical analgesics and antimicrobials noted above, are helpful.
Treatment of sialadenitis consists of rehydration and antibiotic administration. Occasionally, an abscess requires surgical drainage.

Adequate taste and smell no! only ensure proper food selection but also protect against ingesting spoiled food. Anecdotally, gustatory function declines wilh age. although recent data suggest that changes in healthy older persons are modest and tend to affect a specific quality of taste (ic, too sweet, sour, salty, or bitter).
Food enjoyment also requires olfactory and lextural sensory cues. Texlural sensory function appears to undergo Mule or no change with aging. Conversely, olfactory function is markedly impaired. Thus, olfactory function must be assessed in any evaluation of gustatory or food enjoyment complaints.
Hypogeusia, (/ decreased ability to taste, or dysgeusia, a persistent had taste in the mouth, may be associated with neuropathy, upper respiratory infection, drug use (eg, captopril, penicillamine, vinblastine), dental extractions, trauma, menopause, and a host of systemic diseases, but the linkages are weak. Most gustatory complaints are likely to be related to dental status and poor oral hygiene; eg, purulent material from a dental or periodontal abscess may distort gustatory signals. Also, many elderly persons have difficulty maintaining good oral hygiene. Poor hygiene, particularly around teeth with extensive restorations or dental prostheses, may result in chronic unpleasant taste sensations.
Diagnosis
Assessment of gustatory complaints begins with I he history. Paticnis should be asked if (hey can tasle salt when added to soup, the sweetness of sugar when added lo tea. (he sourness of lemon juice, and the bitter taste of coffee. Affirmative answers indicate a likely olfactory deficit rather than (asle loss. Gross taste function can be assessed using these simple chemicals, which define (he four basic tasle qualities. When a patient complains of an unpleasant taste (and if it is usually associated with meals or can be rinsed away with water), suspicion should center on dental disease and dental hygiene. If no local cause seems likely, history of head trauma or upper respiratory disease should be checked. Cranial nerve evaluation should include Ihe first (olfactory), seventh (facial), ninth (glossopharyngeal), and tenth (vagus) nerves.
Tests for taste: Detailed, meaningful tests of gustatory function arc difficult to administer in a typical clinical setting. If Ihe above screening procedures arc inadequate, referral to a chemosensory center for intensive testing may be necessary.
Tests for Olfaction: A reliable and easy-to-use odor recognition tcsl is the University of Pennsylvania Smell Identification Test. It is a prepackaged, scralch-and-sniff lest that requires minimal supervision during administration and is easy (o score.
Treatment
There are no good therapies for gustatory dysfunction. Zinc preparations appear to have little more than a placebo effect. If olfactory disorders relate to airway obstruction, surgical correction may be possible. Meticulously documenting complaints and reassuring patients (hat measurable sensory deficits arc noted often helps and is appreciated.

The oral molor apparatus is involved in finely coordinated functions, including speaking, chewing, swallowing, and facial posture. In general, aging is associated with morphologic and biochemical alterations in neuromuscular systems. Several sludies of oral motor function in healthy adults demonstrate measurable changes in molor performance with age. Reduced masticatory muscle performance is common and appears to lead lo an increased tendency lo swallow larger food particles than usually attempted at a younger age. This practice could result in choking or aspiration. A prolonged oral phase of swallowing similarly may interfere with deglutilion.
Motor changes are of greater concern in non heal thy. elderly patients. Obviously, frank neuropathies may markedly affect the oral-maxillo-faeial musculature. However, most oral motor dysfunctions arc iatrogenic and not necessarily directly related lo the neuromuscular apparatus; thus, any treatment thai diminishes salivary gland function may negatively affect the timing and pattern of the oral swallowing phase. Drugs (eg. antihypertensives, anticholinergics, antipsychotics, and antidepressants) can significantly affect salivary performance (see TABLI-: 52-1). Diminished saliva is also seen in patients after irradiation or surgery for head and neck neoplasms. Additionally, some drugs (eg. phe-nothiazines) are often associated with tardive dyskinesia in (he oral and maxillofacial region.
Certain characteristic changes in voice and speech production occur with age. However, aging is nol normally associated with impaired ability to produce speech and thus is not a general clinical concern.
Many postural alterations occur with age. The lower face and lips may droop because of decreased tone of the circumoral muscles and (in edentulous persons) reduced bone support. This change is both an aesthetic concern and a potential source of embarrassment, since it can lead to drooling or food spills. Healthy older persons may also have difficulty closing their lips competently while ealing, sleeping, or even resting. Loss of circumoral muscle tone is oi’ten first recognized when the person complains of excessive saliva.
Oral motor dysfunction is best managed by a multidisciplinary approach. Coordinated referrals to specialists in prosthetic dentistry, rehabilitative medicine, speech pathology, and gastroenterology may be needed.

Alveolar bone, an important component of the periodontium, provides support for the teeth and is clearly different from the underlying jawbone (mandible and maxilla). Although a general loss of bone mass occurs with age, resorption of alveolar bone is a resull of local factors rather than a part of the aging process. Once dentition (part or all) is lost, alveolar bone is not needed and atrophy quickly ensues. This problem will likely decline as dentition is better preserved.
Fabricating an effective dental proslhesis for patients with severely resorbed alveolar bony ridges is difficult. Upper dentures with a large surface area on the hard palate can usually be adjusted to fit satisfactorily. However, the mandibular arch may be particularly hard lo fit. Endosseous metallic implants (typically titanium) or posts can be surgically placed (especially in edentulous lower jaws) to support dental prostheses and should be considered for patients who report increasing difficulty in retaining dentures.
The installation and proper fit of dentures is important. The loss of dentition and supporting bone affects facial height and results in a tendency toward prognathism, which may contribute to a diminished self-image. Loss of teeth or improperly fitted dentures may adversely affect the patient’s dielary selection and nutrition.
Temporomandibular Joint
The temporomandibular joinl (TMJ) is located between the maxillary glenoid fossa and the condylar process of the mandible and is structurally unique. It is essential to all articulated maxillary and mandibular functions and is involved in many craniofacial pain disorders. Temporomandibular disorders are a constellation of symptoms involving the TMJ and muscles of mas lira! ion. Most affected persons are in their third, fourth, and early fifth decades, and temporomandibular disorders decrease with advancing age. A commonly held view that patients with these disorders have a higher incidence of psycho pathology is not well supported in controlled research.
The TMJ is subject to the symptoms and signs associated with most arlhritides. Osteoarthritis is often delectable by the presence of crepitus and degenerative changes on tomographic imaging. Other common temporomandibular disorders include displacement of the TMJ disk and myofascial pain in the masseter and temporal muscles. Clinical signs include jaw clicking and a reduced range of mandibular motion (< 40 mm tntraincisal distance). Pain is the most common complaint and can include otalgia and neck pain as well as pain referred to otherwise healthy teeth.
The clinician should examine the preauricular areas for joint noises (click, crepitus) and for tenderness in the TM.I and in the masseter, temporal, and pterygoid muscles. Gross evaluation of the occlusion is indicated, although the degree to which occlusion is causative in temporomandibular disorders is controversial. Magnetic resonance, tomographic, or panoramic imaging may rule out inlra-arlicular or bone disease. A diagnosis of temporomandibular disorder should be deferred until more serious extra- and intracranial abnormalities have been excluded (eg, common geriatric conditions such as trigeminal neuralgia and temporal arteritis).
Treatment should be directed loward providing support lo the affected struciures and reducing and eliminating aggravating factors such as teelh clenching (bruxism). Specialists should include a dentist with expertise in temporomandibular disorders, a physical therapist, and when indicated, a psychiatrist or psychologist. Typical treatment consists of an inte [occlusal appliance, short-term physical therapy, behavior modification, and nonsteroidal anti-inflammatory drugs; therapy can include a soft diet, muscle relaxants, and moist heat. Complete or partial edentulism (anodontia) may complicate treatment.

Oral carcinoma, which represents 3% to 5% of all forms of cancer, is a serious concern in the elderly. Its prevalence is low until middle age but increases .sharply thereafter. Oral cancers tend to occur twice as often in men as in women.
Close attention should he directed at persons with clearly defined risk factors, ie. those who smoke cigarettes and those who regularly drink alcoholic beverages. Less common risk factors are pipe and cigar smoking. Smokeless (chewing) tobacco appears to be related to verrucous carcinoma (a highly diffcrentialed variant of squamous cell carcinoma).
The diagnosis of oral cancer is often problematic because of the many ill-defined or variable-appearing lesions that can occur in the mouth. Most are benign, (hough (hey may easily be confused clinically with a malignancy. Conversely, malignant changes can appear quite benign. Typically, (he chief complaint is a sore in the mouth. White, red. or ulcerated lesions thai persist > 3 wk should he evaluated by a dentist or oral surgeon. Induration, fixation, and lymphadenopalhy indicate advanced lesions. The lesion’s clinical history and other oral findings dictate whether biopsy is indicated. Carcinoma should be part of the differential diagnosis of many oral lesions.
About 90% of oral cancers are delected in Ihe following high-risk sites: ihe floor of Ihe mouth, (he oral and basal portions of the tongue, the oropharynx, and the lips. Buccal and labial vestibular carcinoma should be considered in people who use smokeless tobacco. Patients with an oral cancer arc al high risk (up to 33%) for developing a second primary neoplasm in the mouth, pharynx, larynx, esophagus, or lung. Therefore, patients identified as having an oral cancer should be screened in all these siles (eg, using indirect laryngoscopy, chest x-ray) and reexamined annually.
More than any other factor, the stage of these cancers determines the prognosis. While oral cancers < 1 cm in diameter are easily cured, mosl lesions are not diagnosed before they have metastasized to lymph nodes. Therefore, 5-yr survival rates remain al 30% to 40%. This unfortunate situalion appears to result from inadequate knowledge of appropriate screening procedures.

Oral mucosa in older persons has been stereotypically characterized as pale, thin, atrophic, dry. and readily Iraumalized. However, little hard evidence is available to support this. Despite tiuanlitativc hislo logic evidence of epithelial atrophy with age, lliere is no indication that this is clinically significant. Many age-related local changes, such as varicosities and Fordycc’s granules, also have no clinical significance. For example, varicosities in the floor of the mouih, the ventral surface of the tongue, and the hypopharynx rarely bleed. In general, the critical barrier function oflheoral mucosa is well maintained in healthy adulis, regardless of age.
Most complaints are probably manifestations of a systemic disease (Sjogren’s syndrome) or conditions (side effects of drugs or head and neck irradiation) that diminish salivary gland performance (see below). Other conditions (eg. certain endocrinopathies and nutritional deficiencies) can also adversely affect the oral mucosa.
Older edentulous or partially edentulous persons frequently present with traumatic lesions—erythematous, hyperplastic, hyperkeratotic, or ulcerative—secondary to ill-fitting dental prostheses. Patients with such lesions should be referred to a dentist for a new prosthesis or repair of the old one.
If painful ulcerations occur, palliative topical agents may be helpful, eg. 0.5%dydoninc elixir combined with an equal amount of diphenhydramine elixir. This combination requires compounding by a pharmacist. It can be applied with a cotton-tipped applicator directly to intraoral ulcerations if there are only a few. However, as an oral rinse. 5 ml, of the mixture as needed can relieve the pain of a generalized stomatitis. Nutritional counseling (to avoid spicy and irritating foods) may also be required until the mucositis is alleviated. If (issue is considerably hyperplastic, surgery may be necessary to allow normal chewing.
Burning sensations oJ the oral mucosa have been reported, particularly by postmenopausal women. These symptoms are rare, and their etiology is unclear. Patients with so-called burning mouth syndrome represent a spectrum of problems. Psychologic factors are considered important in the course of (his syndrome, but many patients show signs of neurologic dysfunction, vitamin deficiency, poor oral hygiene, or salivary hypofunclion. Some burning mouth complaints are associated with candidiasis (see below). Some patients with burning mouth syndrome can be difficult and frustrating to manage, but they may benefit from referral to an expert in treating chronic pain syndromes. Complete, apparently spontaneous, remission is not uncommon.
Oral candidiasis can occur in older persons wilh dental prostheses (under a denture or at the labial commissures), in those with salivary hypofunction. and in those taking antibiotic or immunosuppressive drugs long term. Candidal hyphae indicate that (he oral mucosal barrier has been breached; therefore, the patient is al risk for systemic infection. Treatment with antieandidal agents is required, eg, an oral suspension of nystatin 100,00(1 to 400.000 u. 3 to 6 times/day for 14 days or clotrimazole troches 10 mg 5 times/day for 14 days.

Principal prophylactic measures involve good oral hygiene. An antimicrobial (antiplaque) mouthwash containing chlorhexidine is effective and is particularly useful for persons who have difficulty with dental hygiene because of diminished dexterity. However, regular use may stain teeth and composite resin dental restorations. These tenacious stains can be removed from the teeth by professional prophylaxis. However, resin restorations may be permanently discolored.
Local or systemic antibiotics in conjunction with periodontal debridement have been suggested for aggressive periodontitis. Because both mixed anaerobic and facultative bacleria are associated with adult periodontitis, no single antibiotic is completely suitable. Nevertheless, after analysis of the microbial population, appropriate short-term systemic antibiotic therapy is useful for some older patients (eg. tetracycline 250 mg/day for 7 to 21 days: doxycycline 100 mg/day for 14 lo 21 days: metronidazole 200 to 250 mg tid lor 5 to 14 days; or amoxicillin and clavulanate potassium 25(1 mg tid for 10 to 14 days).
Surgery may not be necessary because active periodontal disease seems lo be less common in older persons, and confounding syslemic factors (eg, use of anticoagulant or immunosuppressive drugs) may contraindicate it. Nonsteroidal anti-inflammalory drugs, as an adjunct to traditional prophylaxis, appear lo help slow periodontal tissue destruction.
Disease of the tooth’s supporting structure, including the gingiva, alveolar bone, and periodontal ligament.
Pathophysiology, Symptoms, and Signs
Most tooth loss in adulls stems from periodontal disease, usually associated with gingival recession. Like dental caries, periodontal disease is caused by bacterial plaque that accumulates and adheres to the teeth. Bacterial antigens penetrate periodontal tissues; this penetration initiates an inflammatory response and results in local immunopatho-logic destruction of connective tissues.
Periodontal disease tends to progress slowly, in an episodic pattern. Initially, gingiva bleeds and becomes edematous—a hallmark sign (gingivitis), later, destruction of alveolar bone and the periodontal ligament (periodontitis) results in loss of support for the tooth (see FlO. 52—1). A person’s periodontal status represents the accumulation of lesions over a lifetime.
Many common clinical situations can aggravate periodontal disease; eg, diabetes may cause an exaggerated inflammatory reaction with poor tissue response and healing. Drugs also can affect periodontal status. Some (eg, cyclosporine, nifedipine, and phenytoin) may irritate the gums and cause gingival hyperplasia. Others (eg, antihypertensives, psychoactive drugs, and anticholinergics) can reduce saliva production and thereby diminish the key endogenous protective mechanism in the mouth (sec SALIVARY GLAND DISORDERS, below).
Prophylaxis and Treatment
Principal prophylactic measures involve good oral hygiene. An antimicrobial (antiplaque) mouthwash containing chlorhexidine is effective and is particularly useful for persons who have difficulty with dental hygiene because of diminished dexterity. However, regular use may stain teeth and composite resin dental restorations. These tenacious stains can be removed from the teeth by professional prophylaxis. However, resin restorations may be permanently discolored.
Local or systemic antibiotics in conjunction with periodontal debridement have been suggested for aggressive periodontitis. Because both mixed anaerobic and facultative bacleria are associated with adult periodontitis, no single antibiotic is completely suitable. Nevertheless, after analysis of the microbial population, appropriate short-term systemic antibiotic therapy is useful for some older patients (eg. tetracycline 250 mg/day for 7 to 21 days: doxycycline 100 mg/day for 14 lo 21 days: metronidazole 200 to 250 mg tid lor 5 to 14 days; or amoxicillin and clavulanate potassium 25(1 mg tid for 10 to 14 days).
Surgery may not be necessary because active periodontal disease seems lo be less common in older persons, and confounding syslemic factors (eg, use of anticoagulant or immunosuppressive drugs) may contraindicate it. Nonsteroidal anti-inflammalory drugs, as an adjunct to traditional prophylaxis, appear lo help slow periodontal tissue destruction.

Bacterial antigens penetrate periodontal tissues; this penetration initiates an inflammatory response and results in local immunopatho-logic destruction of connective tissues.
Periodontal disease tends to progress slowly, in an episodic pattern. Initially, gingiva bleeds and becomes edematous—a hallmark sign (gingivitis), later, destruction of alveolar bone and the periodontal ligament (periodontitis) results in loss of support for the tooth (see FlO. 52—1). A person’s periodontal status represents the accumulation of lesions over a lifetime.
Many common clinical situations can aggravate periodontal disease; eg, diabetes may cause an exaggerated inflammatory reaction with poor tissue response and healing. Drugs also can affect periodontal status. Some (eg, cyclosporine, nifedipine, and phenytoin) may irritate the gums and cause gingival hyperplasia. Others (eg, antihypertensives, psychoactive drugs, and anticholinergics) can reduce saliva production and thereby diminish the key endogenous protective mechanism in the mouth (sec SALIVARY GLAND DISORDERS, below).

A discuse characterized by decalcification of I Iw tooth’s inorganic portion and accompanied or followed by disintegration of Ihe organic portion, resulting from the action of microorganisms.
In the past, elderly persons were likely to be edentulous. With advances in denial preservation, they are more often dentate and dental caries is seen more often.
Pathophysiology
Dental caries results from dissolution of the tooth surface by microbial by-products found in denial plaque. The type of caries most often affeeling the elderly occurs on the root surface (root caries). Loss of alveolar (supporting) bone around teeth is seen in older persons, and rool surfaces become exposed to the oral milieu (see FlG. 52-D. Ce-mentum, the mineralized substance surrounding the root surface, is an extracellular matrix with about 50% less mineral content (han the enamel matrix covering the crown. Thus, rool surfaces in older persons may be increasingly susceptible (o abrasion, attrition, and demineral-ization.
Root caries is about four times more prevalent in elderly than in younger persons. Coronal caries (decay on the crown of the tooth) is more common among children, adolescenls. and young adults. However, older persons are still susceptible to coronal caries, which usually recurs around reslorations. Generally, rool caries is more difficult to repair than coronal caries. The rapid and extensive appearance of root caries in an elderly patient often signals marked salivary dysfunction (sec SALIVARY GLAND DISORDERS, below).
Prophylaxis and Treatment
All forms of caries should be treated promptly. Untreated caries will progress and penetrate the dental pulp: may cause considerable pain, discomfort, and local infection; and ultimately will enlail more extensive therapy—eg, an exodontic procedure (extraction! or endodontic procedure (rool canal therapy). The elderly should have regular dental care, including prophylaxis (fluoride rinses, plaque and (artar removal) to limit caries. A dental examination once every b mo is usually adequate, but a history of rapidly developing carious lesions or conservatively managed periodontal disease may require more frequent check ups. Older persons with diminished dexterity may need professional prophylaxis more often and individually tailored techniques for oral hygiene.

Two major functions of the oral cavity are to initiate digestion and to allow the production of speech. AM oral tissues have evolved to permi! these activities: The teeth, supporting periodontal tissues, and temporomandibular joint aid in mechanical food processing; Ihe tongue with its finely coordinated movements not on|y mixes and assists in translocating food but also is central to phonation.
Although the mouth is exposed to the oulside environment Ihe oral mucosa provides a barrier against pathogens. Saliva protects oral (issues with its lubricatory. antimicrobial, and dental-remineralizing proteins. Saliva also helps to break down food and to transform it into a swallow-ready bolus. ‘Ihe mouth has an intricate sensory control sys-lem. including exquisitely developed receptors for pain, taste, texture, and temperature.
Denial and oral disorders affect all of the tissues and functions mentioned above. Most problems are not life threatening, but they may be serious and may impacl greatly on Ihe quality of life.