NMDA Journal Summer 2018

19 nmdental.org changes. The volume of the chamber declines as secondary dentin is deposited. The blood vessels and nerves in the pulp decline with a loss of myelinated nerve fibers and a gain of dystrophic calcium.  5, 6 Many of the deficits traditionally thought to be associated with aging are actually signs of pathologic processes. Physiologic changes associated with aging can impact every system in the body and have an effect on the way dental care is delivered.  7 Overall, changes occur for all people, tissues, and organs; and, these changes occur with differing rates and individual variability. However, many of the deficits traditionally attributed to aging are actually signs of pathologic processes.  7 Geriatricians often assert that age alone does not seem to play a role in impaired oral health. Rather, it is the result of aggregate effects due to oral diseases, systemic conditions, polypharmacy, and head and neck radiation which predispose older persons to developing oral and pharyngeal disorders.  1 OVERALL, THE MAJOR RESULTS OF THE AGING PROCESSES ARE: a) a reduced biologic reserve of many body functions (i.e., heart, lungs, kidney); b) an impaired homeostasis mechanism by which bodily activities are kept adjusted (i.e, fluid balance, tempera- ture control and blood pressure con- trol); and, c) impaired immunologic system, as well as related increased incidence of neoplastic and age-related autoimmune conditions.  8 The important point to make here is that overall health is important to oral health among the elderly, and vice versa.  9, 10 The elderly are more susceptible to systemic conditions predisposing them to develop oral diseases which can directly or indirectly lead to malnutrition, altered communication, further susceptibility to infectious diseases, and diminished quality of life.  8 A major impact of systemic diseases on the oral health of older adults is caused by the side effects of medications: both prescribed and over the counter. With increasing age and associated chronic disease, the elderly are taking an ever- expanding variety ofmedications. Besides the desired therapeutic outcome, adverse side effects may alter the integrity of the oral mucosa and associated oral structures. Problems such as xerostomia (dry mouth), bleeding disorders of the tissues, lichenoid reactions (oral tissue changes), mucositis, tissue overgrowth, altered bone metabolism, and hyper- sensitivity reactions may occur as a result of drug therapy.  11 We, as dental clinicians, have been made very well aware of significant unintended oral consequences produced by medications, such as those in the bisphosphonate groups. This group of drugs, particularly those administered intravenously, has been associated with a condition referred to as Bisphosphonate- associated Osteonecrosis of the Jaws (BONJ), comprising a host of occasionally serious and intractable disturbances to bone healing.  12 Bone remains metabolically active throughout life. Age- related bone loss is extremely common, reflecting an imbalance between bone resorption by osteoclasts and bone formation by osteoblasts. Osteoporosis, a common problem in the elderly, is an age-related disorder characterized by a decrease in bone mass and by an increased susceptibility to fractures. Clinically, advanced osteoporosis can present with chronic back pain, from mechanical strain caused by kyphosis or vertebral compression fractures.  13 Kyphosis is the condition that generally results in the stooping posture and rounded-shoulder appearance of the affected elder. It often impacts the ability of the patient to be positioned adequately in the dental chair without special modifications and accommodations. Recent studies indicate that changes in alveolar bone as a result of osteoporosis may contribute to the progression of periodontal disease.  14 Also, a significant decrease in bone mass of the mandible may lead to fragility and increased resorption, risk of fracture, and failure of osseointegration of implants. Many of us who treat the elderly and fabricate denture prostheses are confounded by the degree of ridge resorption evident in a large percentage of those who are edentulous (Fig 2). Prevention may well include early placement of dental implants while the status of the residual bony ridges is more optimal. Otherwise, prevention rather than treatment, is the key to the management of osteoporosis. Exercise, vitamins, a balanced diet, dietary calcium, and estrogen play a role in the treatment and prevention of osteoporosis.  15 THE MOUTH AS THE “MIRROR” OF HEALTH Reports indicate that 80% of older adults suffer from chronic illness and 50% suffer from at least two infectious diseases.  15 Injuries also take an unbalanced toll on older adults resulting from osteoporosis, poor nutrition, head and neck cancers, heart disease, diabetes, mental incapability, decreased muscle mass, arthritis and other diseases and complications.  8 Through observation Fig 2—Mandibular atrophic residual ridge. Notice the floor of the mouth elevates above the crest of the mandibular ridge. The patient will receive two mandibular implants prior to denture fabrication. (Photograph courtesy of Stephen Wagner, DDS, FACP) continues on next page 