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An autoimmune disorder that affects the salivary glands, called Sjögren syndrome, is commonly seen in post-menopausal women (Bowen & Pieren, 2020).

The body's immune system attacks the glands that make moisture in the body, such as the mouth, eyes and other body cavities. Sjögren syndrome can damage the nervous system, lungs and kidneys in addition. It can also accompany other autoimmune disorders like systemic lupus and rheumatoid arthritis (U.S. Department of Health and Human Services, 2021).

Signs include ropy saliva, dry oral mucosa, and atrophy of the papillae on the tongue, making the surface lobulated and smooth (Bowen & Pieren, 2020).

Signs and symptoms can also include burning, itching, irritation, light sensistivty and inflamed eyes.

A person with Sjögren syndrome can have symptoms and signs that involve only the mouth, only the eyes or both.

The disorder is chronic, and there is no cure, but there are ways to manage symptoms, such as using saliva substitutes (U.S. Department of Health and Human Services, 2021).

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With age, salivary gland changes include the volume of fibrous tissue and fat increase in the submandibular and parotid glands. In contrast, the amount of secretion produced by the acinar cell reduces. These changes are related to salivary gland hypofunction.

A study was conducted on elderly men on the labial salivary gland tissue, and moderate to severe fibrosis and acinar atrophy were found in almost 50 percent of the participants.

With age, reflexes and stimulation have a decreased intensity, which leads to a change in the salivary gland function (Xu et al., 2018).

The salivary glands also go through changes unrelated to age, resulting in decreased salivary flow due to medications, systemic conditions, radiation in the head or neck and tumours (Bowen & Pieren, 2020).

Some oral manifestations that can be seen because of hyposalivation include burning in the tongue (dysesthesia), taste altered (dysgeusia), bad breath, difficulty swallowing (dysphagia), atrophy of filiform papillae, a red tongue, red oral mucosa, and dry lips (CDHO, 2014).

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Xerostomia is commonly referred to as ‘dry mouth.’ Xerostomia has many potential causes, such as salivary gland blockage, disease and dysfunction. It is also common when taking over-the-counter or prescription medications daily—medications such as antihistamines, muscle relaxants, antihypertensives, antidepressants, laxatives and antipsychotics (Bowen & Pieren, 2020).

Signs include cervical caries, tongue blade sign (which is a test when a tongue blade touches the oral mucosa, if it sticks or not), increased biofilm since there is a decrease in saliva to wash it away, frequent oral infections such as burning mouth syndrome, symptomatic geographical tongue, oral candidiasis, and angular cheilitis (CDHO, 2014).

Steps to manage xerostomia:

Saliva substitutes

Xylitol gum or mints

Mouth rinses

Oral lubricants

Drinking lots of water

Brushing with fluoride toothpaste twice a day

Using interdental aids daily

Nutritional counselling

Using phosphate and amorphous calcium pastes

Debridement often by a dental professional

Getting professionally applied fluoride

Dry mouth places individuals in the high caries risk bracket, meaning they should have regular dental visits (Bowen & Pieren, 2020).

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There is a link between periodontal disease and old age from repeated immune system challenges throughout one’s life cycle.

Due to the accumulation of microbial changes throughout life, the periodontium ages, which creates a greater susceptibility to acquiring periodontal disease.

With age comes increased recession, greater risk for gingival inflammation, and loss of attachment.

Changes specific to the gingiva include the thinning of epithelium, nerve degeneration, reduced number of nerves, increased cellular density, hardening of gingival vessels and keratinization.

Evidence has shown changes to the periodontal ligament, including increased calcification and diminished cellular function.

Another link between the elderly and a higher prevalence of periodontal disease includes fewer dental visits, the greater occurrence of systemic diseases, and increased local risk factors such as more restorations.

Older individuals should visit the dental office often to receive debridement, instruction on proper oral hygiene, and education on chemotherapeutics and interdental aids (Bowen & Pieren, 2020).

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The loss of permanent teeth is the biggest change seen in older adults.

The loss of teeth is also known as edentulousness.

Less financially secure individuals are more likely to become edentulous than financially secure individuals (Bowen & Pieren, 2020).

20% of older adults over the age of 65 are entirely edentulous (CDC, 2021).

Aging is not the cause of tooth loss; in fact, one of the main reasons for tooth loss in the elderly is due to periodontal disease. When plaque buildup is not removed by brushing, flossing or other interdental aids, the bacteria will travel below the gum line and cause bone loss and tissue destruction. Most of the time, periodontal disease is not detected, which increases the risk of tooth loss.

Another significant cause of tooth decay is xerostomia, commonly found in the elderly as a side effect of their many medications. Without a moist oral cavity, bacteria remains in the mouth, which will help form cavities, causing decay and tooth loss.

Systemic conditions are also linked to tooth loss. For example, there is a link between uncontrolled diabetes and the acceleration of periodontal disease and tooth decay. With uncontrolled diabetes, blood vessels become damaged from high blood sugar; as a result, the blood vessels are not supplying enough blood to the gingiva leading to an increased susceptibility to infection. There is also increased sugar found in the oral fluids from high blood sugar; this increased sugar will feed bacteria, further progressing decay in the teeth.

Other systemic conditions linked with inflamed gingival tissues include blood pressure, respiratory problems, heart disease and stroke (Harvard Health Publishing, 2010).

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As individuals age, their teeth which include the enamel, cementum, dentin, and pulp goes through many changes.

The lifelong ingestion of foods and drinks that produce stains such as coffee can cause the enamel to become darker in colour. The enamel can also become translucent as it forms cracks, also known as acquired lamellae.

Cementum can have an increase in fluoride and magnesium content as adults age. Cementum deposition at the apices and furcation areas makes up for coronal enamel tooth wear.

Dentin changes by the formation of secondary dentin and the sealing of dentinal tubules can result in decreased vitality of dentin and dentin in the older adult may become impermeable and insensitive.

The pulp will undergo changes such as a decrease in cells, an increase in fibres, and a decrease in blood. The size of the pulp chamber will decrease with age due to an increase in pulp calcification which can form in unerupted and erupted teeth.

Attrition, abrasion, and erosion are all common conditions that are seen in older adults.

Attrition is clinically seen as the flattening or smoothing of the incisal or occlusal surfaces and in severe cases, dentin may be exposed and seen on the incisal or occlusal edges. Hygienists should be cautious when instrumenting to avoid causing more trauma to fissured enamel that may be apparent.

Abrasion may be prevalent with today’s older population as growing up they might have been using a stiffer toothbrush or a toothpaste that is very abrasive which would since have been taken off the market.

Erosion may be common in the older population to those who have a diet that consists of acidic foods and drinks or those individuals that suffer from acid reflux (Bowen & Pieren, 2020, p. 775-776).

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The older patient is more likely to be diagnosed with coronal and root caries than the younger patient due to age-related factors and local factors.

18.5% of individuals aged 65-74 have at least one untreated area of decay and 19.4% of individuals aged 75 years or older have at least one untreated area of decay.

Local factors can include exposed roots from recession and the longevity of teeth.

Age-related factors include factors such as the quality and quantity of saliva, decreased dexterity which inhibits adequate oral self-care, chronic health conditions, and reduced mastication abilities.

Caries can be caused by high amounts of caries-causing bacteria called streptococcus mutans, xerostomia, the presence of plaque, and recession. As well, caries can form more rapidly when oral hygiene is absent and when fermentable carbohydrates are ingested frequently.

Education to the older adult patient and/or the patient's caregiver is important for preventing caries by means such as cutting back on refined carbohydrates, mechanical and chemical control of plaque biofilm, salivary replacement therapy, and through fluoride treatment. Fluoride treatments can be done professionally or at home. A common agent that is used for coronal and root caries is sodium fluoride.

With the decrease in dexterity in older adults, tools such as powered toothbrushes can be used to help remove plaque biofilm more adequately. Patients can also adjust handle sizes for an easier grip. Toothpaste and mouth rinses with antimicrobial agents such as sodium fluoride can help reduce and prevent bacteria from forming (Bowen & Pieren, 2020, p. 776-777).

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Sublingual Varicosity           https://www.intechopen.com/chapters/46198    	 

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As we start to age, common changes on the tongue include the loss and decreased sensitivity of papillae. Alongside these changes, there may be a decrease in the sense of smell that may make certain foods less appealing which can result in an individual not ingesting enough nutrients.

Anemia, which is an iron deficiency, can arise from individuals not meeting nutritional needs. A condition that is common among anemic patients is atrophic glossitis which can cause a burning sensation on the tongue and make it clinically appear shiny and smooth.

In edentulous patients, the tongue may increase in size due to a condition called pernicious anemia. If a patient has this condition, the hygienist should proceed with a diet counselling session as well as recommend an oral lubricant to lessen patient discomfort.

A benign clinical finding that occurs among the older population is sublingual varicosities. Sublingual varicosities can occur on the ventral surface of the tongue and are blue, red, or black in colour which represents dilated vessels (Bowen & Pieren, 2020, p. 779).

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Papillary Hyperplasia of the Palate                                          https://ars.els-cdn.com/content/image/1-s2.0-S0266435606001549-gr1.jpg 

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A healthy person's oral mucosa does not go through any changes as they age. Mucosal changes in the older population can be a result of medications or systemic factors that are prevalent within the oral cavity.

Since the older population makes up 1/3 of over-the-counter prescriptions, it is important that we are aware of the adverse reactions that can arise. Medications that can cause oral candidiasis which is a fungal infection include antibiotics such as amoxicillin and medications that cause xerostomia.

The labia mucosa is commonly affected by factors such as dehydration and reduced elasticity within the tissues. These factors can cause angular cheilitis to arise which is seen clinically as fissuring, cracks, and ulcerations at the corners of the lips.

Oral mucosa changes can also erupt from ill-fitting dentures or improper care of dentures. There are three common conditions that can happen in these cases which include denture stomatitis, chronic atrophic candidiasis, and denture-induced fibrous hyperplasia (Bowen & Pieren, 2020, p. 778). Denture stomatitis, which is also known as ‘Papillary Hyperplasia of the Palate’ is associated with ill-fitting dentures and poor oral hygiene. Clinically it appears as red granular/cobblestone papillary projections on the hard palate (Ibsen & Peters, 2023, p. 63-64). Chronic atrophic candidiasis, also known as ‘sore mouth’, is caused by ill-fitting dentures which can lead to trauma and denture retention which allows for bacteria and fungi to grow. Denture-induced fibrous hyperplasia can be singular or multiple elongated folds on the vestibular area near the denture border. Clients should be made aware of how to properly care for dentures and the dangers of ill-fitting dentures to prevent bacterial/fungal infections.

Screening for oral cancer is an important step in the dental hygiene process of care as it can cause early detection of oral cancer signs (Bowen & Pieren, 2020, p. 778).

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While the elderly community only consists of 13% of the population, they make up 1/3 of over-the-counter prescriptions. Elderly individuals are more likely to undergo adverse reactions from drugs due to the use of multiple medications interacting and as well physiological changes in the kidneys, liver, and heart.

Many adverse reactions include oral changes and conditions which is why is it so important for dental hygienists to take a thorough medication summary highlighting any conditions that may arise and educating the client on these conditions if they are present within the oral cavity (Bowen & Pieren, 2020, p. 779).

The most common condition among the older population is hypertension with 58% of individuals being treated for high blood pressure (The Top 10 Most Common Chronic Conditions in Older Adults, 2021). A medication that is commonly given to treat hypertension is Lisinopril. Lisinopril can cause adverse reactions such as xerostomia, Steven-Johnson syndrome, which is a fatal condition, and dysgeusia which is a taste disorder (Lisinopril, 2023).

Other medications that cause adverse reactions include phenytoin, an anticonvulsant that may cause gingival hyperplasia. Medications such as nifedipine which is a cardiovascular drug and cyclosporine which is an immunosuppressant may cause gingival enlargement. In both gingival enlargement and hyperplasia cases, plaque control is extremely important (Bowen & Pieren, 2020, p. 779).

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Bowen, D. M., & Pieren, J. A. (2020). Darby and Walsh Dental Hygiene: Theory and Practice (5th ed.). Elsevier.

Centers for Disease Control and Prevention. (2021, May 5).  Oral Health for Older Americans. CDC. Retrieved February 16, 2023, from https://www.cdc.gov/oralhealth/basics/adult-oral-health/adult_older.htm#:~:text=Tooth%20loss.,65%2D74%20(13%25).

College of Dental Hygienists of Ontario. (2014). Xerostomia. CDHO Factsheet Xerostomia. Retrieved February 16, 2023, from https://www.cdho.org/Advisories/CDHO_Factsheet_Xerostomia.pdf

Harvard Health Publishing. (2010, January 1). The aging mouth - and how to keep it younger. Harvard Health Publishing Medical School. Retrieved February 16, 2023, from https://www.health.harvard.edu/diseases-and-conditions/the-aging-mouth-and-how-to-keep-it-younger

Ibsen, O. A. C., & Peters, S. M. (2023). Oral Pathology for the dental hygienist: With general

pathology introductions (8th ed.). Elsevier.

Lisinopril. Shibboleth authentication request. (2023). Retrieved February 15, 2023, from

https://online-lexi-com.georgian.idm.oclc.org/lco/action/doc/retrieve/docid/dental_f/47475?cesid=11zwKRkCNiH

The Top 10 Most Common Chronic Conditions in Older Adults. The National Council on

Aging. (2021, April 23). Retrieved February 15, 2023, from https://www.ncoa.org/article/the-top-10-most-common-chronic-conditions-in-older-adul

U.S. Department of Health and Human Services. (2021, April 7). Sjögren's syndrome. National Institute of Arthritis and Musculoskeletal and Skin Diseases. Retrieved February 16, 2023, from https://www.niams.nih.gov/health-topics/sjogrens-syndrome

Xu, F., Laguna, L., & Sarkar, A. (2018). Aging‐related changes in quantity and quality of saliva: Where do we stand in our understanding? Journal of Texture Studies, 50(1), 27–35. https://doi.org/10.1111/jtxs.12356