Introduction
The increase in the number of elderly in Indonesia is the result of increased life
expectancy.[1] Health problems in the elderly can be influenced by psychological, social, and economic
aspects. Additionally, the aging process causes several changes to the morphology
and physiology of organs and organ systems, including those of the oral cavity.[2] Several studies have shown that prevalence of normal variance of oral mucosa in
the elderly is higher than in adults and children.[3]
[4]
[5] In India, the prevalence of changes in oral soft tissue conditions in the elderly
is 89.4% higher than in other age groups.[3] In Kuwait, studies show that the highest prevalence of oral soft tissue lesions
occur in elderly patients.[4] Another research conducted in Surabaya, Indonesia, showed that the normal variances
of the mucosa with higher prevalence in the elderly are coated tongue, fissured tongue
and lingual varices.[5] These conditions can affect daily activities, including mastication, swallowing,
and talking, as well as cause symptoms such as xerostomia, halitosis, or dysesthesia.[6]
It is important to distinguish between normal aging processes and pathological conditions
in the elderly population. Lack of knowledge about the changes in the oral cavity
due to aging can lead to excessive or unnecessary oral management, so normal variance
and pathological abnormalities of the oral cavity in the elderly need to be properly
evaluated.[7] Until now, there is little data available in the literature that can describe the
prevalence of oral normal variance in healthy elderly people, which means optimum
service standards for the elderly do not yet exist. Oral health services must be regulated
and improved for both the development of preventive efforts and better treatment of
healthy elderly. Achieving such improvements require the involvement of other oral
health professionals, such as dentists, as well as other health workers so that the
realistic goal of ensuring the quality of life of the elderly can be achieved, and
so we can reduce the cost of dental treatments for elderly patients. This research
was conducted so that, in the future, it can be applied as a guide to improve the
oral health of elderly patients, and provide optimum service standards for elderly
patients.
Materials and Methods
Study Design
This descriptive observational study with cross-sectional design was conducted in
elderly patients from March to April 2020.
Study Participants
All the participants of this study are elderly. Informed written consent forms were
obtained from the patients who were willing to participate in the study. The inclusion
criteria of the sample in this study were age over 60 years old, cooperative, and
healthy elderly. In this study, we defined healthy elderly patients as those without
degenerative diseases (hypertension, diabetes mellitus, coronary heart disease, or
chronic kidney disease) that could be assessed for medical history and anamnesis.
Intraoral Examination
A screening examination, which included an intraoral clinical exam, was performed
by an oral medicine specialist and students from the oral medicine specialist program.
Intraoral examination was done by using an intraoral mirror, and oral mucosa was screened
for all soft tissue lesions. Normal variance of the mucosa or pseudo lesions considered
as a form of soft tissue variation from its normal shape were diagnosed based on clinical
examination. The normal variance, or pseudo lesions, of the mucosa were determined
based on the della Vella et al. study of 2019, with modifications[8] ([Table 1]).
Table 1
The pseudo lesions and their location
|
Location
|
Normal variance of the mucosa
|
|
Tongue
|
Fissured tongue
|
|
Crenated tongue
|
|
White and black hairy tongue
|
|
Coated tongue
|
|
Sublingual varices
|
|
Lingual fimbriae
|
|
Papilla circumvallate prominent
|
|
Papilla foliate prominent
|
|
Hyperpigmented papilla of tongue
|
|
Depapilated tongue, including geographic tongue
|
|
Oral mucosa
|
Linea alba buccalis
|
|
Fordyce granules
|
|
White sponge nevus
|
|
Steno's duct orifice hyperplasia
|
|
Gingiva
|
Racial pigmentation on gingiva
|
|
Bone
|
Torus palatinus
|
|
Torus mandibularis
|
Data Presentation
The data obtained will be presented descriptively through percentages, and by using
a prevalence rate analyzed using the Microsoft Excel 2020 (Microsoft Corp., Redmond,
WA, USA) software.
Results
Subject Demographic
A total of 117 elderly patients participated in this study, but 59 elderly patients
were excluded because of degenerative diseases. After the exclusion, our cohort comprised
58 healthy elderly patients, with the diagnosis of one or more oral normal variances.
The demographic data from those subjects can be found in [Table 2]. The majority of the subjects were in the age range of 60 to 74 years, and almost
all of them were women.
Table 2
Demographic data from healthy elderly participating in this study
|
Demographic aspect
|
Number of subjects
|
Percentage
|
|
Gender
|
|
|
|
Male
|
3
|
5.17%
|
|
Female
|
55
|
94.83%
|
|
Age
|
|
|
|
60–74 years old
|
53
|
91.38%
|
|
75–90 years old
|
5
|
8.62%
|
|
>90 years old
|
0
|
0%
|
Intraoral Examination
We identified seven normal variances of the oral mucosa: fissured tongue (93.1%),
coated tongue (58.62%), crenated tongue (27.59%), lingual varices (15.52%), atrophic
glossitis (3.44%), linea alba buccalis (1.72%), and hyperpigmented papilla of the
tongue (1.72%). The clinical appearance of those oral normal variances can be found
in [Fig. 1]. As previously described, the most common normal variance found in this study was
fissured tongue ([Table 3]).
Fig. 1 Clinical appearance of oral normal variance in healthy elderly. (A) fissured tongue and atrophic glossitis; (B) coated tongue; (C) crenated tongue; (D) lingual varices, and (E) linea alba buccalis.
Table 3
Prevalence of pseudo lesions in healthy elderly
|
Oral normal variance
|
Number of subjects
|
Percentage
|
|
Fissured tongue
|
54
|
93.1%
|
|
Coated tongue
|
34
|
58.62%
|
|
Crenated tongue
|
16
|
27.59%
|
|
Lingual varices
|
9
|
15.52%
|
|
Depapilated tongue
|
2
|
3.44%
|
|
Linea alba buccalis
|
1
|
1.72%
|
|
Hyperpigmented papilla of the tongue
|
1
|
1.72%
|
|
Total subjects
|
58
|
100%
|
Discussion
According to the literature, the main oral health problems in the elderly are dry
mouth and dental caries, which are associated with reduced salivary flow.[9] These problems can worsen the presence of normal variance in the oral cavity of
the elderly. As mentioned before, oral soft tissue lesions can interfere with daily
activities, including mastication, swallowing, and talking, as well as cause symptoms
such as xerostomia, halitosis, or dysesthesia. Therefore, treatment is paramount to
improve the health of the oral cavity of the elderly.[6]
Aging affects the structure of the oral cavity, altering the teeth, periodontal tissue,
mucosa, salivary glands, bone tissue, and taste buds.[2] The changes that occur include: Loss of elasticity and reduced vascularization in
the oral mucosa, with a pale, thin, dry, and smooth aspect. The epithelium becomes
more permeable, meaning it becomes more susceptible to various harmful substances,
mechanical injuries, and irritant agents, as well as to microbes and fungi. Physical
and immunological defense of the mucosa is impaired and the regenerative ability is
reduced, making it more susceptible to injury.[6] The atrophy of the salivary gland's cell walls, especially in the ducts, causes
a decrease in the salivary flow and results on the oral mucosa becoming dry and loosing
elasticity, as well as lip rupture and fissures on the tongue. The tongue loses filiform
papillae, making it appear smooth, and often there is an increase in lingual varices
on the ventral surface.[10]
Oral normal variance may occur with aging as a predisposing factor. It is important
to identify general variations in the normal anatomy of the oral cavity and clinical
findings that can be associated with systemic, psychological and behavioral conditions,
especially in the elderly. Clinical findings of normal oral variance can assist clinicians
in providing appropriate oral health services.[11] In vulnerable age groups, such as the elderly, there is a lot of normal variance
in the oral cavity, especially lesions on the tongue, which are indicators of specific
needs for oral intervention.[10]
In this study, it was found that 93.1% of the healthy elderly patients had a fissured
tongue, which was the largest prevalence. Some other studies also found that fissured
tongue is common in the elderly. The city of Maharashtra, India, presented the highest
prevalence of abnormalities, reporting 51.7% of cases of fissured tongue.[12] In the Airlangga University Hospital, the prevalence of fissured tongue was 25.40%,
which makes it fourth most common lesion.[5] In India, it was reported that fissured tongue was the second-largest type of lesion
found, amounting to 20.1%.[13] Fissured tongue or lingua fissurata, plicated tongue, scrotal tongue, and groove
tongue are lesions that are often found in the general population.[14] The etiology has not yet been fully elucidated, but some argue that it is due to
congenital factors; however, various other factors also play a role in the development
of fissured tongue such as aging, hyposalivation, diabetes mellitus, candidiasis,
and vitamin B deficiency.[12] According to the study of Maloth et al., the statistical analysis shows that the
prevalence of fissured tongue increases significantly with age.[15] With the high prevalence of fissured tongue in the elderly of Posyandu Lansia at
the Public Health Center of Surabaya, it is essential to educate the elderly on good
oral hygiene, specifically in relation with the tongue, to clean debris, and reduce
the risk of microbial infection and halitosis.[16] Fissured tongue usually does not cause pain, except in the cases of food debris
collecting in the grooves, which can result in infections, inflammation, and irritation.[8] If these lesions cause pain due to infection, then the treatment aims to reduce
inflammation and infection.[16]
Coated tongue can occur due to the accumulation of debris on the tongue.[11] The high prevalence of coated tongue in the elderly is supported by the Omor et
al. study, which proved statistically that the prevalence of coated tongue increases
with age. The use of mouthwash and tongue brushing can improve tongue hygiene and
reduce coated tongue.[17]
Crenated tongue can be caused by tongue pressure, such as the habit of pressing the
tongue against the teeth, pushing the tongue, sucking the tongue, bruxism, macroglossia,
and tongue thrusting.[8]
Lingual varices are developmental anomalies in old age. The etiology of this lesion
is not known with certainty. But according to other studies, lingual varices are related
to age, smoking, and cardiovascular diseases.[16] These lesions occur due to changes in the connective tissue or weakening of the
venous wall, as a result of degeneration of elastic fibers associated with the aging
process. These lesions do not require special treatment, except for aesthetic and
personal reasons.[11] Lingual varices are harmless lesions, can be diagnosed clinically, and do not require
treatment. Surgical excision can be performed for varicose thrombosis, and for the
aesthetic importance of lip varicosities.[8]
Depapillated tongue, also known as atrophic glossitis, is characterized by loss of
the tongue's papilla. This can be related to the emergence of burning sensation in
some patients. The tongue's surface with loss of papillae is characterized by a red
area on the dorsal surface of the tongue. Atrophic glossitis usually occurs in patients
with nutritional deficiencies, xerostomia, lichenoid reaction, local trauma, candidiasis,
and because of the aging process.[18] The oral mucosa in the elderly becomes thinner and smoother. The tongue undergoes
clinical changes and is smoother because of the loss of the filiform papillae.[9]
[19]
Linea alba buccalis is a hyperkeratosis lesion associated with recurrent pressure,
frictional trauma, and other parafunctional habits from the buccal surface of the
tooth. There is no specific treatment for this lesion, as it arises because of friction
trauma.[11] Linea alba buccalis usually does not cause pain. Some patients experience fear,
because they mistake it for cancer. The treatment of this lesion is accomplished by
eliminating the irritant.[20] Prevalence analysis with various factors that can cause linea alba buccalis can
help determine the treatment quickly and prevent the emergence of further complications.[21]
It is important for health practitioners, including dentists, to increase their treatment
standards and provide better service to the elderly, such as education about oral
health and how to manage and treat normal variances. The limitation of this study
is that we only used a clinical diagnosis to diagnose the normal variance of oral
mucosa. Some normal variances need different tests and exams to reach the final diagnosis.
Conclusion
The most prevalent oral normal variance identified in this study was fissured tongue.
However, the results of the current study should be interpreted with caution, and
conducting new studies regarding oral hygiene, smoking, and racial populations, with
large random samples would be highly recommended. Future studies need a bigger sample
to diagnose more normal variances of oral mucosa.
