Article Not peer-reviewed version

Age-Related Changes in Oral Health,

Salivary Parameters, Halitosis, and
Systemic Diseases and Medication
Usage

Solsol Seo , Tae-Seok Kim , Yeon-Hee Lee *

Posted Date: 28 August 2024

doi: 10.20944/preprints202408.2091.v1

Keywords: aging; oral health; saliva; halitosis; systemic disease; systemic medication

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Article

Age-Related Changes in Oral Health, Salivary

Parameters, Halitosis, and Systemic Diseases
and Medication Usage
Solsol Seo 1,†, Tae-Seok Kim 1,† and Yeon-Hee Lee 2,*
1 Department of Dentistry, Graduate School, Kyung Hee University, #613 Hoegi-dong, Dongdaemun-gu,
Seoul 02447, Korea
2 Department of Orofacial Pain and Oral Medicine, Kyung Hee University Dental Hospital, Kyung Hee

University, #613 Hoegi-dong, Dongdaemun-gu, Seoul 02447, Korea

* Correspondence: [email protected]; Tel.: +82-2-958-9409
† These authors contributed equally to this work.

Abstract: Background The increasing number of elderly individuals in South Korea, now entering
a super-aging era, underscores the growing importance of understanding their specific oral health
needs. This study investigated changes in oral health conditions, salivary parameters, halitosis,
systemic diseases, and medication usage with aging. Methods This study was retrospectively
conducted using the medical records of patients who presented with complaints of xerostomia or
halitosis between August 2020 and May 2023. A total of 274 patients (66 males, 208 females, mean
age 59.39 ± 16.10 years) were included in this study. Results Aging was found to be significantly
associated with the presence of sticky saliva, poor oral hygiene, tongue coating, and halitosis (all p
< 0.05). Correlation analyses further revealed significant associations between aging and several
conditions, including hypertension (r = 0.495, p < 0.001), diabetes mellitus (r = 0.255, p < 0.001),
amlodipine usage (r = 0.249, p = 0.001), osteoporosis (r = 0.195, p = 0.001), cardiovascular disease (r
= 0.150, p = 0.013), and the presence of tongue coating (r = 0.205, p = 0.001). Conversely, none of the
salivary parameters demonstrated a significant relationship with aging. Furthermore, halitosis did
not exhibit significant differences across age groups (all p > 0.05), with the exception of methyl
mercaptan levels, which were notably higher among patients in their 20s (p = 0.049). Conclusions
The findings of this study can help clinicians develop targeted strategies to address specific oral
health challenges associated with aging in elderly patients.

Keywords: aging; oral health; saliva; halitosis; systemic disease; systemic medication

1. Introduction
South Korea is entering the age of super-aging society. The 2015 Census of Older People
estimates that proportion of those who aged 65 and over in South Korea is 13.2%, and forecasts that
the proportion will continue to rise and reach 20.0% in 2025, entering the super-aging society [1,2]. In
the era of super-aging society, the importance of maintaining general health of elderly is steadily
increasing, and one of the crucial factors in general healthcare of elderly is managing oral health [3].
Inadequate oral health management can result in various oral diseases, such as dental caries and
periodontal disease, and elderly individuals with unmanaged oral conditions are at an elevated risk
for systemic diseases, including diabetes mellitus, dementia, pulmonary infections, and
cardiovascular disease [4–6]. Therefore, a thorough understanding of the oral health status and
related factors in the elderly is essential for effective management.

© 2024 by the author(s). Distributed under a Creative Commons CC BY license.

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Elderly individuals experience various changes in their oral health, which can complicate oral
health management. Xerostomia is a common condition among the elderly, with previous studies
indicating a significantly higher prevalence of subjective dry mouth sensations as age increases [7–
9]. Aging is associated with a marked reduction in the function of the submandibular and sublingual
glands, leading to a decreased salivary flow rate and changes in the composition of whole saliva,
resulting in sticky saliva [10,11]. This reduced salivary flow and sticky saliva can impair the oral self-
cleansing mechanism, increasing the risk of oral conditions related to poor oral hygiene, such as food
impaction, tongue coating, and calculus deposition [12]. Poor oral hygiene can directly cause
halitosis, as oral health problems are responsible for more than 90% of halitosis cases [13]. While the
relationship between age and halitosis remains debated, several studies have reported a high
prevalence of halitosis among the elderly due to an increase in oral health-related issues [14–16].
Furthermore, an important aspect of aging is the increased prevalence of systemic diseases and
medication usage. In South Korea, the prevalence of systemic diseases is significantly higher among
the elderly and has been steadily rising over time [17]. Correspondingly, the use of systemic
medications is also increasing globally, with particularly high levels of medication usage observed in
the elderly [18,19]. Previous studies have demonstrated that systemic diseases, systemic medication
use, and oral health are interrelated and can exacerbate one another; for instance, diabetes mellitus
can lead to xerostomia, and poor oral hygiene can worsen hypertension [3,20]. Therefore, the
increased prevalence of systemic diseases and medication use among the elderly must be carefully
considered to effectively maintain both oral and systemic health in this population.
Despite the growing need to understand the oral health conditions, systemic diseases, and
medication usage among the elderly, there remains a lack of comprehensive studies investigating
changes in oral health, salivary parameters, halitosis, and systemic medication use with aging,
particularly those involving large patient cohorts. This study aims to examine the changes in oral
health conditions, salivary parameters, halitosis, systemic diseases, and medication usage associated
with aging. The primary hypothesis of this study is that aging is associated with a higher prevalence
of poor oral health conditions, xerostomia, halitosis, systemic diseases, and increased medication
usage, and that there may be complex interrelationships among these factors.

2. Materials and Methods

2.1. Research Subjects and Groups
This study targeted patients aged between teens to 80s who visited the Department of Orofacial
Pain and Oral Medicine at Kyung Hee University Dental Hospital from August 2020 to May 2023,
complaining xerostomia or halitosis. For sample size calculation, we used G*Power software (ver.
3.1.9.7; Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Germany), found that 220 participants
were suitable for statistical analysis (α level = 0.05, the power = 0.90, and the effect size = 0.5). After
screening, 303 patients were selected, and 29 patients were excluded due to the insufficient medical
records. A total 274 patients (66 males, 208 females, mean age 59.39 ± 16.10) were enrolled in this
study. Patients were then divided into eight age groups according to 10-year increments: teens into
age group 1, 20s into age group 2, and so on until age group 8.

2.2. Evaluation of Saliva

Evaluation of salivary parameters was performed at the patients’ initial visit, using GC Saliva
Check Buffer kits (GC Company, Tokyo, Japan). Evaluated salivary parameters were salivary flow
rate, salivary pH, and salivary buffer capacity, using the spitting method. First, patients were ordered
to spit their saliva for 10 minutes in resting state. The amount of collected saliva was recorded as
unstimulated flow rate (UFR). After measuring UFR, a salivary pH test strip was inserted into the
unstimulated whole saliva, and salivary pH was recorded according to the color change of test strip
(Figure 1). Next, patients were ordered to chew paraffin wax gum for 2 minutes, and spit their saliva
for 5 minutes. This amount of collected saliva was recorded as stimulated flow rate (SFR). After
measuring SFR, stimulated whole saliva was dropped onto the three areas of the buffer test strip
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using a pipette, and salivary buffer capacity was recorded according to the color change of buffer test
strip with the salivary buffer indicator (Figure 2). In terms of diagnosis criteria, normal UFR is 0.3-
0.4ml/min, and normal SFR is 1.5-2.0ml, while hyposalivation is diagnosed when UFR is under
0.1ml/min or SFR is under 0.7ml/min [21]. Normal salivary pH is between 6.7-7.3, and abnormal
salivary pH is under 6.3 [22]. Additionally, since there are several measuring methods for salivary
buffer capacity, this study followed the guideline of manufacturer of salivary test kit, GC company,
where score between 10-12 is normal salivary buffer capacity, 6-9 is low, and 0-5 is very low. All of
the salivary evaluation procedures were performed by skilled dentists and dental hygienists, trained
in standardized examination protocol.

2.3. Evaluation of Halitosis

The level of halitosis was also evaluated at the patients’ initial visit. Halitosis examination was
conducted using the TwinBreasor II (IsenLab, Gyeonggido, Korea), which separates and measures
hydrogen sulfide (H2S) and methyl mercaptan (CH3SH) in parts per billion (ppb). Prior to the halitosis
measurement, patients were instructed to refrain from smoking and eating food for 30 minutes. With
the mouth closed, a syringe for gas collection was placed deeply into the patients’ oral cavity without
touching the tongue or saliva, and gas was collected. Collected gas was inserted to the device and
analyzed, and the results were derived and recorded (Figure 3). VSC was calculated with sum of H2S
and CH3SH. Halitosis was diagnosed when H2S is over 112ppb or CH3SH is over 26ppb [23].

Figure 1. Test strip for salivary pH and dental saliva pH indicator. After applying the test strip to
collected saliva, color of the test strip was compared to a standard color chart to determine the closest
match. In the presented figure, salivary pH was interpreted as 7.4.
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(A) Paraffin wax and buffer strip

(B) Salivary buffer indicator

Figure 2. Paraffin wax, buffer strip, and salivary buffer indicator. Patients were indicated to chew
paraffin wax to collect stimulated salivary flow rate. Collected stimulated saliva was dropped on
buffer strip, and changed color was recorded according to the salivary buffer indicator.

Figure 3. Result page of halitosis evaluation. Levels of hydrogen sulfide (H2S), methyl mercaptan
(CH3SH) were recorded.
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2.4. Evaluation of Oral Health Condition

The oral health condition of each patient was evaluated and recorded during their first visit by
skilled dentists. Sticky saliva was identified when frothy or viscous saliva was observed with the
naked eye. Oral hygiene was categorized into three grades—good, moderate, and poor—based on
the clinician's subjective assessment. Calculus deposition was recorded when visible calculus was
detected. Tongue coating was noted if the patient exhibited a white or yellowish coating on the
posterior two-thirds of the tongue. Oral ulcers were documented if any visible ulcers were present
on the oral mucosa. Oral candidiasis was confirmed through a swab culture, which involved
collecting an oral specimen with a sterile transport swab (Transystem, COPAN, Italy), culturing it in
the appropriate medium, and evaluating the resulting specimen. All culture procedures followed the
criteria established by the Department of Laboratory Medicine at Kyung Hee University Medical
Center.

2.5. Evaluation of Systemic Disease and Medication

Systemic diseases and medication of patients were collected from the questionnaire at the
patients’ initial visit. Systemic diseases were divided into hypertension, diabetes mellitus,
osteoporosis, and cardiovascular disease, which are the four most prevalent systemic disease.
Patients with overlapping diseases among hypertension, diabetes mellitus, osteoporosis, and
cardiovascular disease were classified repeatedly to each group. Medications of patients were also
recorded by classifying the medications into four categories: Amlodipine tab (amlodipine),
Metformin tab (metformin), Alend tab (alendronate), and Lasix tab (furosemide).

2.6. Statistical Analysis

Data were analyzed using IBM SPSS for Windows (version 26.0; IBM Corp., Armonk, NY, USA).
Descriptive statistics, including means and standard deviations, were calculated to summarize the
data. The distribution of categorical data was analyzed using the χ² test and Bonferroni tests for the
equality of proportions. Analysis of variance (ANOVA) followed by Tukey’s post-hoc test was
employed to compare parameter values among different age groups. Cramer’s V analysis was
conducted to identify associations between aging and other oral and systemic parameters. The
correlation coefficients (r) were calculated to assess the strength of the correlations, ranging from -1
to 1, with values closer to ±1 indicating stronger relationships. Linear regression analysis and
generalized linear models were used to explore the relationship between aging and oral health. Given
that systemic diseases and medication use were strong contributors to aging, an adjusted model
accounting for these factors was employed to isolate the relationship between aging and oral health.
The adjusted generalized linear model was constructed with age as the dependent variable and oral
health conditions and salivary parameters as independent variables. The correlation coefficients (B),
standard errors, p-values, and 95% confidence intervals (95% CIs) were calculated. For all analyses,
statistical significance was set at a two-tailed p-value of < 0.05.

2.7. Ethics Approval and Consent to Participate

The procedures for human subjects in this study were conducted according to the ethical
standards of the Committee on Human Experimentation of our institution and the 1975 Declaration
of Helsinki. This study was approved by the appropriate ethics review board of the Kyung Hee
University Dental Hospital (IRB No. KH-DT23022). Informed consent was obtained from all
participants in this study.

3. Results
3.1. Gender and Age Distribution of Patients
Age and gender distribution of patients are presented in Table 1. Of the 274 participants of the
study, 66 (22.8%) were male and 208 (71.7%) were female, for about 1:3 ratio of females to males. The
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number of patients for each age group is as follows: 9 individuals (3.3%) in their teens (age group 1),
10 (3.6%) in their 20s (age group 2), 11 (4.0%) in their 30s (age group 3), 30 (10.9%) in their 40s (age
group 4), 63 (23.0%) in their 50s (age group 5), 66 (24.1%) in their 60s (age group 6), 67 (24.5%) in their
70s (age group 7), and 18 (6.6%) in their 80s (age group 8). Mean age of total patients was 59.39 ±
16.10.

Table 1. Gender and age distribution.

Features n (%) Male n (%) Female n (%) p-value

Male 66 (24.1)
Sex - - -
Female 208 (75.9)
Group 1 (age 10s) 9 (3.3) 5(55.6%) 4(44.4%)

Group 2 (age 20s) 10 (3.6) 6(60.0%) 4(40.0%)

Group 3 (age 30s) 11 (4.0) 3(27.3%) 8(72.7%)

Group 4 (age 40s) 30 (10.9) 6(20.0%) 24(80.0%)

Age
Group 5 (age 50s) 63 (23.0) 11(17.5%) 52(82.5%) 0.028*

Group 6 (age 60s) 66 (24.1) 13(19.7%) 53(80.3%)

Group 7 (age 70s) 67 (24.5) 19(28.4%) 48(71.6%)

Group 8 (age 80s) 18 (6.6) 3(16.7%) 15(83.3%)

Total 274 (100.0) 66(24.1%) 208(75.9%)
The results of this analysis were derived using chi-square tests and post-hoc analyses. Significance set
at p < 0.05. *p < 0.05; ** p < 0.01; *** p < 0.001.

3.2. Salivary Parameters by Age Group

Salivary parameters for age groups are displayed in Figure 4 and 5. Across the age groups, there
was no significant difference in the UFR (p = 0.229), SFR (p = 0.971), salivary pH (p = 0.606), and
salivary buffer capacity (p = 0.344). For UFR, age group 2 had the lowest mean value (0.28±0.18
ml/min) and age group 8 had the highest mean value (0.60±0.36 ml/min). For SFR, age group 1 had
the lowest mean value (1.27±0.39 ml/min) and age group 8 had the highest mean value (1.51±0.64
ml/min). All of the age groups were in the normal range of salivary flow rate. For salivary pH, age
group 2 had abnormal salivary pH (6.18±0.62), which was the lowest mean value among the age
groups. Also, all of the age groups showed slightly lower salivary pH than normal range except for
age group 8 (6.77±0.63), which was the highest mean value among the age groups. For salivary buffer
capacity, only age group 1 (10.67±1.22) and age group 3 (10.82±1.25) had normal salivary buffer
capacity, and age group 3 had the highest mean value. Other age groups had lower salivary buffer
capacity than normal range, and age group 2 had the lowest mean value (9.00±2.67).

3.3. VSC Levels by Age Group

VSC levels for different age groups are presented in Table 2 and Figure 5C. Age group 2 showed
significantly higher mean level of CH3SH (152.00±214.96 ppb) than the other age groups (p = 0.049),
and it was the only age group with higher level of CH3SH than normal range. For H2S, age group 2
had the highest mean value (410.00±579.82 ppb) followed by age group 3 (318.50±635.00 ppb), and
both groups had the higher level of H2S than normal range. However, relationship between H2S and
age groups was not statistically significant (p = 0.393). For VSC, age group 2 had the highest mean
value (112.40±355.44 ppb), but it was not statistically significant difference with the other age groups
(p = 0.051). The percentage of patients diagnosed with halitosis was highest in age group 2 (10.0%),
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followed by age group 4 (3.3%), age group 5 (3.2%), age group 6 (3.0%), age group 7 (1.5%), and age
groups 1, 3, and 8 (0.0%). However, the prevalence of halitosis did not show a significant association
with age group (p = 0.807).

2.6
2.4 UFR SFR
Salivary flow rate (ml/min)

2.2
2.0
1.8
1.6
1.4
1.2
1.0
0.8
0.6
0.4
0.2
0.0
Group 1 Group 2 Group 3 Group 4 Group 5 Group 6 Group 7 Group 8

Age group

Figure 4. Salivary flow rate by age group. The results of this analysis were obtained by ANOVA and
post-hoc analysis. There was no significant difference in UFR and SFR across the age groups (all p >
0.05). UFR: Unstimulated Flow Rate, SFR: Stimulated Flow Rate.

(A) Salivary pH by age group

7.8
7.6 Salivary pH
7.4
7.2
7.0
Salivary pH

6.8
6.6
6.4
6.2
6.0
5.8
5.6
5.4
5.2
5.0
Group 1 Group 2 Group 3 Group 4 Group 5 Group 6 Group 7 Group 8
Age group
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(B) Salivary buffer capacity by age group

13.0
12.5 Salivary buffer capacity
12.0
11.5
Buffer capacity

11.0
10.5
10.0
9.5
9.0
8.5
8.0
7.5
7.0
6.5
6.0
Group 1 Group 2 Group 3 Group 4 Group 5 Group 6 Group 7 Group 8
Age group

(C) H2S, CH3SH, and VSC levels by age group

1200
H2S
1000
CH3SH
Halitosis level (ppb)

800 VSC
600

400

200 *
0

-200

-400
Group 1 Group 2 Group 3 Group 4 Group 5 Group 6 Group 7 Group 8

Age group

Figure 5. Salivary parameters and VSC levels by age group. The results of this analysis were
obtained by ANOVA and post-hoc analysis. There was no significant difference in salivary pH and
buffer capacity across the age groups (all p > 0.05). * p < 0.05 indicates a significantly higher mean level
of CH3SH in age group 2, compared with other age groups. H2S: Hydrogen sulfide, CH3SH: Methyl
mercaptan, VSC: Volatile Sulfur Compounds.
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Table 2. Halitosis levels by age group.

Group 1 Group 2 Group 3 Group 4 Group 5 Group 6 Group 7 Group 8

Age 10s Age 20s Age 30s Age 40s Age 50s Age 60s Age 70s Age 80s

Featu p-

(n = 9) (n = 10) (n = 11) (n = 30) (n = 63) (n = 66) (n = 67) (n = 18) Post-hoc

res value

Mean±SD Mean±SD Mean±SD Mean±SD Mean±SD Mean±SD Mean±SD Mean±SD

or n (%) or n (%) or n (%) or n (%) or n (%) or n (%) or n (%) or n (%)

Age

<0.00 Age group

(year 15.89±3.26 24.20±1.74 36.27±3.04 45.33±3.09 54.57±3.07 64.26±2.88 74.04±2.91 82.72±2.22

1*** 1<2<3<4<5<6<7<8

H2S 410.00±579. 318.50±635.

0.00±0.00 1.00±1.00 26.50±22.81 68.00±99.58 7.89±12.34 0.00±0.00 0.393 -

(ppb) 82 00

CH3S

152.00±214. Age group 2 >

H 0.00±0.00 0.00±0.00 5.25±9.18 6.00±6.93 11.50±20.37 9.22±16.86 0.00±0.00 0.049*

96 Others

(ppb)

VSC 112.40±355. 43.17±235.4

0.00±0.00 0.273±0.65 2.06±9.74 4.82±32.00 2.30±10.50 0.00±0.00 0.051 -

(ppb) 44 9

Halit

0 (0.0%) 1 (10.0%) 0 (0.0%) 1 (3.3%) 2 (3.2%) 2 (3.0%) 1 (1.5%) 0 (0.0%) 0.807

osis

The results of this analysis were obtained by ANOVA and post-hoc analysis. Significance set at p <
0.05. *p < 0.05; ** p < 0.01; *** p < 0.001. Statistically significant results are indicated in bold. SD:
Standard Deviation, H2S: Hydrogen sulfide, CH3SH: Methyl mercaptan, VSC: Volatile Sulfur
Compounds.

3.4. Distribution of Representative Systemic Diseases by Age Group

Distribution of the four representative systemic diseases is displayed in Figure 6. There was a
significant difference in the prevalence of hypertension across the age groups (p = 0.001), with
significantly higher incidence in older age groups (age group 7 and 8) than other age groups. The
prevalence of hypertension was highest in age group 8 (77.8%), and was in the decreasing order of
age group 7 (64.2%), age group 6 (42.4%), age group 5 (19.0%), age group 4 (10.0%), age group 3
(9.1%), age group 1 (0.0%), and age group 2 (0.0%). Regarding to diabetes mellitus, prevalence of
diabetes mellitus was also significantly different across the age groups (p = 0.010) with significantly
higher incidence in older age groups (age group 7 and 8) than other age groups. It was highest in age
group 7 (22.4%), and in the decreasing order of age group 8 (22.2%), age group 6 (13.6%), age group
5 (4.8%), age group 4 (3.3%), and age group 1,2, and 3 (0.0%).
In contrast, there was not statistically significant difference in prevalence of osteoporosis (p =
0.099) and cardiovascular disease (p = 0.235) across the age groups. Prevalence of osteoporosis was
highest in age group 8 (11.1%), followed in decreasing order of age group 7 (10.4%), age group 6
(3.0%), age group 5 (1.6%), and age groups 1, 2, 3, and 4 (0.0%). Prevalence of cardiovascular disease
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10

was highest in age group 6 (22.4%), followed by in decreasing order of age group 7 (22.2%), age group
8 (13.6%), age group 5 (4.8%), and age groups 1, 2, 3, and 4 (0.0%).

90

80
Hypertension ***
Diabetes
70
Osteoporosis ***

60
Prevalence rate (%)

Cardiovascular disease

50

40

30
** **
20

10

0
Group 1 Group 2 Group 3 Group 4 Group 5 Group 6 Group 7 Group 8

Age group

Figure 6. Distribution of representative systemic diseases by age group. The results of this analysis
were obtained by Pearson chi-square test and post-hoc analysis. *** p < 0.001 indicates a significant
difference of prevalence of hypertension in age group 7 and 8, compared with age group 1 to 6. ** p <
0.01 indicates a significant difference of prevalence of diabetes mellitus in age group 7 and 8,
compared with age group 1 to 6.

3.5. Correlation between Age, Halitosis, and Salivary Flow Rate

Table 3 presents the result of correlation analysis between age, halitosis, and salivary flow rate.
VSC and complaint of halitosis were strongly correlated (r = 0.621, p < 0.001). UFR and SFR also
showed a statistically strong correlation (r = 0.513, p < 0.001).

3.6. Correlations between oral health, systemic disease, and medication with aging
The associations between oral health, systemic medication, systemic disease, and aging are
summarized in Table 4. Among the oral health conditions, tongue coating showed a significant
association with aging (r = 0.205, p = 0.001). In terms of systemic medications, amlodipine was the
only medication significantly associated with aging (r = 0.249, p = 0.001). Furthermore, all four
systemic diseases were strongly correlated with aging, with hypertension showing the strongest
correlation (r = 0.495, p < 0.001), followed by diabetes mellitus (r = 0.255, p < 0.001), osteoporosis (r =
0.195, p = 0.001), and cardiovascular disease (r = 0.150, p = 0.001).
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11

Table 3. Correlations between age, halitosis, and salivary flow rate.

VSC UFR SFR

Correlation
(ppb) Halitosis (mL/min) (mL/min)

Correlation 0.052 0.054 −0.024 0.082

Age (years)
Coefficient

p-value 0.392 0.371 0.690 0.178

Correlation 1.000 0.621 0.038 0.083

VSC Coefficient

(ppb) p-value <0.001*** 0.533 0.171

Correlation 1.000 −0.010 0.074

Coefficient

Halitosis p-value 0.871 0.221

Correlation 1.000 0.513

UFR Coefficient

(mL/min) p-value <0.001***

Correlation 1.000

SFR Coefficient

(mL/min) p-value
The results of this analysis were obtained using Cramer’s V analysis. Significance set at p < 0.05. ***p
< .001. Statistically significant results are indicated in bold. UFR: Unstimulated Flow Rate, SFR:
Stimulated Flow Rate, VSC: Volatile Sulfur Compounds, VAS: Visual Analog Scale.

Table 4. Correlations between medications by age and oral health.

Aging

Features Correlation
p-value
coefficient

Sticky saliva 0.022 0.721

Oral hygiene 0.087 0.152

Oral health
Calculus deposition 0.005 0.930

Tongue coating 0.205 0.001***

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Ulcer 0.023 0.701

Oral candidiasis 0.063 0.299

Amlodipine 0.249 0.001***

Systemic Metformin 0.031 0.614

medication Alendronate 0.118 0.051

Furosemide 0.068 0.278

Hypertension 0.495 <0.001***

Systemic Diabetes mellitus 0.255 <0.001***

disease Osteoporosis 0.195 0.001**

Cardiovascular diseases 0.150 0.013*

The results of this analysis were obtained by Cramer’s V analysis. Significance set at p < 0.05. *p < .05;
**p < .01; ***p < .001. Statistically significant results are indicated in bold.

3.7. Generalized Linear Model of Oral Health, Salivary Parameters and Aging
A generalized linear model was employed to predict aging using oral health conditions and
salivary parameters. In this model, aging was selected as the independent variable, while oral health
conditions and salivary parameters were treated as dependent variables. The results of the
generalized linear model are presented in Table 5. Among the oral health conditions, oral hygiene
was found to be strongly associated with aging, with both poor oral hygiene (B = 11.752, 95% CI =
2.219–21.286, p = 0.016) and moderate oral hygiene (B = 6.903, 95% CI = 1.880–11.926, p = 0.007)
showing significant relationships. Notably, poor oral hygiene exhibited the largest coefficient value
among the factors analyzed. Other oral health conditions that were significantly associated with
aging included the presence of sticky saliva (B = 6.039, 95% CI = 1.368–10.709, p = 0.011), the presence
of tongue coating (B = 4.615, 95% CI = 0.681–8.549, p = 0.021), and the presence of halitosis (B = 0.774,
95% CI = 0.216–1.332, p = 0.043). In contrast, none of the salivary parameters showed a significant
relationship with aging (all p > 0.05).

Table 5. A generalized linear model using oral health and salivary parameters to predict aging.

95% Wald CI
Parameter B SE p-value
Lower Upper
Sticky saliva [ref.=none] 6.039 2.383 1.368 10.709 0.011*
Oral hygiene_poor [ref.=good] 11.752 4.864 2.219 21.286 0.016*
Oral hygiene_moderate [ref.=good] 6.903 2.563 1.880 11.926 0.007**
Calculus deposition [ref.=none] 2.533 5.711 -8.660 13.725 0.657
Oral ulcer [ref.=none] -5.036 3.5272 -11.949 1.877 0.153
Tongue coating [ref.=none] 4.615 2.007 0.681 8.549 0.021*
Halitosis [ref.=none] 0.774 0.307 0.216 1.332 0.043*
Oral candidiasis [ref.=none] -0.348 1.207 -2.714 2.018 0.773
Salivary pH 0.308 1.239 -2.120 2.735 0.804
Saliva buffer capacity -0.132 0.372 -0.861 0.598 0.724
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UFR 6.332 3.649 -0.821 13.484 0.083

SFR -0.439 1.539 -3.455 2.578 0.776
The results were obtained using a generalized linear model. In the generalized linear model, we
obtained the adjusted model for systemic diseases and systemic medication. Significance set at p <
0.05. *p < .05; **p < .01. Statistically significant results are indicated in bold. UFR: unstimulated salivary
flow rate, SFR: stimulated salivary flow rate, SE: standard error, CI: confidence interval.

4. Discussion
In this study, we aimed to investigate the changes in salivary parameters, halitosis, systemic
diseases, systemic medication usage, and oral health conditions with increasing age. The findings
indicated that increasing age was significantly associated with the presence of sticky saliva, poor oral
hygiene, tongue coating, and halitosis, as demonstrated by the generalized linear model.
Additionally, there was a correlation between increasing age and both amlodipine usage and four
systemic diseases. In contrast, no significant relationship was found between salivary parameters and
increasing age. When analyzing age groups, CH3SH levels were significantly higher in age group 2,
whereas VSC, H2S, and salivary parameters did not differ significantly across age groups. Moreover,
the prevalence of hypertension and diabetes mellitus was significantly higher in age groups 7 and 8,
while the prevalence of osteoporosis and cardiovascular disease did not vary across age groups.
In this study, sticky saliva was significantly more likely to be observed in older adults. Sticky
saliva, characterized by dehydrated saliva with high viscosity, is commonly associated with factors
such as xerostomia, diabetes mellitus, oral infections, and the use of systemic medications, all of
which are more prevalent among the elderly [24–26]. Additionally, sticky saliva is closely linked to
decreased function of the submandibular gland [27]. With advancing age, there is a reduction in the
number of acinar cells and an increase in fatty and fibrous tissue within the salivary glands [28].
These morphological changes are more likely to impair the function of the submandibular and
sublingual glands than the parotid gland in the elderly [29]. This partial reduction in salivary gland
function can lead to saliva with high viscosity, even when the salivary flow rate remains normal,
which may be overlooked by clinicians who focus solely on xerostomia. Given that sticky saliva has
a similar impact as xerostomia on oral conditions, such as reducing self-cleansing activity and
lubrication [30], clinicians should also consider saliva viscosity in their assessments.
This study demonstrated that tongue coating becomes more prevalent with increasing age.
Tongue coating is a significant contributing factor to various oral diseases, such as halitosis and taste
disorders, and can also impact systemic health by spreading to the respiratory or digestive systems
and affecting several metabolic pathways [31,32]. Tongue coating primarily consists of residual food,
bacterial by-products, leukocytes, and keratinized debris, and its presence often indicates poor oral
health and inadequate oral hygiene management [33]. Effective oral health management includes
mechanical cleaning methods, such as tooth brushing and scaling, as well as oral self-cleansing.
Reduced oral self-cleansing ability is closely associated with impaired salivary secretion and
diminished motor function, particularly lingual motor function, in the elderly [34]. Moreover, the
high prevalence of certain systemic diseases, such as diabetes mellitus and stroke, in older adults can
affect oral hygiene and tongue function, contributing to tongue coating formation [35,36]. However,
the precise etiology of tongue coating formation remains controversial and requires further
investigation. Despite this, the finding that elderly patients exhibited more tongue coating in this
study underscores the importance of managing tongue coating in this population.
In this study, overall oral hygiene significantly deteriorated with increasing age. Oral hygiene is
indicative of general oral health conditions, and poor oral hygiene is frequently assessed based on
the presence of specific oral symptoms, including xerostomia, sticky saliva, swollen tissues, ill-fitting
dentures, dental caries, plaque or calculus deposition, and oral ulcers [37]. In the elderly, poor oral
hygiene results from a higher occurrence of oral symptoms related to inadequate hygiene and a
reduced ability to perform dental health-related behaviors, such as toothbrushing, swallowing,
tongue movement, and visiting dental clinics [38]. These behaviors are closely linked to the patient's
physical and cognitive abilities, and the decline in neuromuscular function and the high prevalence
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of systemic diseases in the elderly increase their risk of failing to maintain proper oral hygiene [38–
40]. To effectively address poor oral hygiene in the elderly, dentists should consider not only the
patient's oral health condition but also their need for nursing care and functional rehabilitation.
Regarding halitosis, this study presented mixed results. While the presence of halitosis was
closely associated with aging in the generalized linear model, CH3SH levels were significantly higher
in the group in their 20s, and there were no significant differences in H2S levels, VSC levels, or the
prevalence of halitosis across the age groups. These findings align with previous studies suggesting
that halitosis is not clearly associated with age, or that it is more prevalent among the elderly [15,16].
VSC, the primary cause of halitosis, are predominantly produced from poor oral health conditions,
particularly periodontal disease and tongue coating. However, VSCs are directly produced by the
oral microbiome through the breakdown of sulfur-containing amino acids from food debris, serum,
and other substrates like tongue coating [41]. Poor oral hygiene, which provides a source for VSC
production, is common in the elderly, making the high prevalence of halitosis in this population
understandable. Nonetheless, the total amount of specific oral microbiomes, such as Firmicutes and
Bacteroidetes, which are known to be associated with VSC production, does not change significantly
with age. The proportion of these oral microbiomes may increase in younger individuals with
systemic disease or poor oral hygiene, leading to halitosis in younger populations [42,43]. Therefore,
the correlation between aging and halitosis remains controversial, and further studies with larger
sample sizes and more variables are needed to accurately clarify these conflicting findings.
Contrary to the main hypothesis, salivary flow rate and salivary buffer capacity were not
significantly related with aging. This is the controversial result with the previous studies that whole
salivary flow rate tends to decrease in elderly [10,11]. In fact, several studies commonly reported that
UFR is significantly lower in elderly, but it is controversial whether SFR is decreased in elderly
[28,29]. SFR is mainly composed of saliva from parotid gland, whose function is not significantly
decreased with increasing age, and thus it is possible that SFR is not significantly different with
increasing age [29,44]. Also, regarding to UFR, a study reported that UFR is closely related with oral
condition while SFR is not [44]. Since this study included only patients with oral discomfort, UFR of
younger participants might be influenced to decrease by their poor oral condition, leading to the
insignificant difference with elderly. Further studies would be needed to re-evaluate this result, with
design of case-control study including healthy participants.
In this study, all analyzed systemic diseases were found to be associated with aging, with
hypertension and diabetes mellitus demonstrating particularly strong correlations with both aging
and specific age groups, which aligns with the findings of previous research [45,46]. Additionally,
amlodipine, an antihypertensive medication, demonstrated a significant relationship with aging.
These results underscore the importance of assessing systemic diseases and medication use in the
management of oral health in the elderly. It is well-established that systemic diseases, related
medications, and oral health conditions are closely interconnected [3,20]. Hypertension can lead to
oral conditions such as angioedema, xerostomia, or lichenoid reactions in the oral mucosa, and
patients with periodontal disease have an increased risk of developing hypertension. Additionally,
patients using antihypertensive medications are at a higher risk of experiencing xerostomia, a
condition that is typically more severe in the elderly [25]. Furthermore, diabetes mellitus can lead to
xerostomia and an imbalance of oral microorganisms, resulting in taste disorders, an increased risk
of oral candidiasis, and periodontal disease. Given that the prevalence of hypertension and diabetes
mellitus is steadily increasing in South Korea [47,48], clinicians should place even greater emphasis
on considering systemic diseases during oral healthcare, particularly for the elderly.
Despite the findings of this study, several limitations should be acknowledged. First, the
evaluation of oral health relied on the subjective judgment of the examiners, which may have
introduced inconsistencies. Additionally, the sample was retrospectively derived solely from patients
who visited a single dental hospital, raising concerns about potential selection bias. Furthermore, the
study did not include a control group, which necessitates caution in interpreting the results.
Nevertheless, this study highlights several correlations between aging, oral health, salivary
parameters, halitosis, systemic diseases, and systemic medication.
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5. Conclusion
This study has comprehensively elucidated the changes and correlations among oral health
conditions, salivary parameters, halitosis, systemic diseases, and systemic medication associated with
aging. The findings highlight the higher prevalence of poor oral hygiene and systemic diseases
among the elderly, underscoring the critical need for integrated management of oral health and
related systemic conditions in this population, particularly in light of the growing elderly
demographic in an aging society. By raising local awareness and incorporating these findings into
healthcare planning for the elderly, this study has the potential to enhance the effectiveness of
management strategies, ultimately contributing to improved quality of life and greater stability for
elderly individuals.

Funding: None.

Institutional Review Board Statement: The research protocol for this study was reviewed in compliance with
the Declaration of Helsinki and approved by the Institutional Review Board of Kyung Hee University Dental
Hospital in Seoul, South Korea (KHD IRB, IRB No-KH-DT23022). Informed consent was obtained from all the
participants.

Informed consent statement: Informed consent was obtained from all the subjects involved in the study.

Data Availability Statement: The datasets used and/or analyzed during the current study are available from the
corresponding author upon reasonable request.

Authors' contributions: Writing and original draft preparation, Y-HL, SS and T-SK; conceptualization, Y-HL;
methodology, Y-HL, SS and T-SK; software, Y-HL, SS and T-SK; validation and formal analysis, Y-HL;
investigation, Y-HL, SS and T-SK; resources, Y-HL, SS and T-SK; data curation, Y-HL, SS and T-SK; writing,
review, and editing, Y-HL, SS and T-SK; visualization, Y-HL, SS and T-SK; supervision, Y-HL; project
administration, Y-HL. All authors contributed to and approved the submitted manuscript.

Acknowledgments: None.

Conflicts of Interest: The authors declare no conflict of interests.

Consent for Publication: All authors consented to the publication of this manuscript.

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