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The Journals of Gerontology Series A: Biological Sciences and Medical Sciences 56:M731-M735 (2001)
© 2001 The Gerontological Society of America

Mandibular and Palatal Tori, Bone Mineral Density, and Salivary Cortisol in Community-Dwelling Elderly Men and Women

Jadwiga Hjertstedta, Edith A. Burnsb,d, Raymond Fleminge, Hershel Raffb,f, Inge Rudmanb,d, Edmund H. Duthieb,d and Charles R. Wilsonc

a Division of Oral Medicine and Diagnostic Sciences, Marquette University School of Dentistry, Milwaukee, Wisconsin
b Departments of Medicine, Medical College of Wisconsin, Milwaukee
c Departments of Biophysics and Radiology, Medical College of Wisconsin, Milwaukee
d Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin
e Department of Psychology, University of Wisconsin-Milwaukee
f Endocrine Research Laboratory, St. Luke's Medical Center, Milwaukee, Wisconsin

Jadwiga Hjertstedt, Division of Oral Medicine and Diagnostic Sciences, Marquette University School of Dentistry, P.O. Box 1881, Milwaukee, WI 53201-1881 E-mail: Jadwiga.Hjertstedt{at}marquette.edu.

Decision Editor: John E. Morley, MB, BCh


   Abstract
Top
 Abstract
Methods
 Results
 Discussion
 References
 
Background. This investigation evaluated the relationship between the presence of tori and bone mineral density (BMD) and salivary cortisol levels.

Methods. A total of 230 healthy, community-dwelling elderly men (n = 129) and women (n = 101) aged 60 and older participated in this study. Forty-three women were on hormone replacement therapy (HRT). This was a component of a 5-year longitudinal study measuring subjects' body composition, hormone levels, physical activity, and diet every 6 months. Subjects were examined for the presence of tori by visual inspection and digital palpation. BMD at six sites was measured by dual-energy X-ray absorptiometry. Salivary cortisol levels were measured by radioimmunoassay.

Results. Twenty-three percent of all subjects had mandibular tori, 13% had palatal tori, and 12% had both mandibular and palatal tori. Mandibular tori were more common in men, and palatal tori were more common in women. The presence of mandibular tori was significantly correlated with BMD of the lumbar spine, femoral neck, trochanter, and Ward's triangle for all subjects, and with the femoral neck and trochanter of women not on HRT. Men with palatal tori had lower levels of salivary cortisol in the evening.

Conclusions. This study documented the high prevalence of mandibular and palatal tori in a group of 230 elderly, community-dwelling subjects. Women not on HRT and all subjects taken as a group with mandibular tori had higher BMD. The presence of tori at young adulthood may be a marker of higher BMD in the future and of a lower risk for developing osteoporosis.

MANDIBULAR and palatal tori were first described more than 100 years ago in the anthropological literature (1)(2). They are considered to be relatively rare but normal anatomic formations. These benign bony hyperostoses are asymptomatic and begin to be clinically visible in the second decade of life (3); they cease growing or exhibit only minimal growth after the fourth decade (4). There are no longitudinal studies to suggest that they resorb over time. Mandibular tori (MT), usually bilateral, are located on the lingual aspect of the mandible above the mylohyoid ridge (5)(6) (Fig. 1). Palatal tori (PT) present symmetrically along the mid-suture line of the hard palate. Tori consist of normal cancellous bone covered by a layer of cortical bone. They vary in size, can be flat or lobular, and can present as solitary nodules or multiple nodular masses that coalesce. Their etiology is not fully understood, but hereditary and functional or environmental factors, such as masticatory stress, have been implicated in their manifestation (5)(7).



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  		Figure 1. Photograph of bilateral mandibular torus. The bony hyperostoses are located on the lingual aspect of the mandible, posterior to the canines. Note the presence of a second hyperostosis posteriorly on the left.

 
Osteoporosis is a major health problem in the aging population, manifesting as structural bone changes, loss of bone mass, and increased incidence of fractures (8)(9)(10)(11). Skeletal bone mass reaches its peak in the early thirties and declines with age. The onset of decline in bone mineral density (BMD) in women occurs at an earlier age than in men, although individual variations in the rate and degree of loss are considerable (12). The peak BMD and rate of change of BMD vary at different skeletal sites depending on the ratio of trabecular to cortical bone and on the average use at the site (12). Numerous factors can affect BMD and the development of osteoporosis, including extrinsic factors such as nutrition, medication use, amount of physical activity, lifestyle factors (e.g., smoking and alcohol abuse), and intrinsic factors (e.g., adrenal and gonadal hormone levels). The relationship between BMD and estrogen levels in women has been extensively studied, and an accelerated rate of BMD loss occurs during the immediate post-menopausal period (13). In men, a somewhat later and more gradual loss of BMD has been associated with declining endogenous androgen levels (10)(14)(15). We (16) and others (17)(18)(19)(20)(21)(22) have also recently reported an association between age and elevations in nadir cortisol levels. Our study also found a relationship between higher nadir salivary cortisol and lower BMD in men and in women who have not used hormone replacement therapy (HRT) (16).

As with other bones in the skeleton, mandibular BMD decreases with age (23)(24)(25)(26)(27). In a cross-sectional study of 85 osteoporotic women and 27 normal women, Kribbs and colleagues (25)(26) demonstrated decreased mandibular BMD and a thinner cortex at the gonion in osteoporotic women. Another study reported greater cortical bone width and overall BMD of the mandible in men compared with women and declining BMD in both genders after age 50 (28). Autopsy studies have found an inverse correlation between mandibular BMD and age, with lower values found in women compared with men at all ages (29)(30)(31). Because tori appear to stop growing at approximately the time that peak BMD is reached, we hypothesized that the two phenomena might be interrelated. We are unaware of any studies evaluating the relationship between tori and BMD. The purpose of this study was to evaluate the relationship between the presence of tori and BMD and salivary cortisol levels in a group of community-dwelling elderly men and women.


   Methods
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 Abstract
 Methods
Results
 Discussion
 References
 
Subjects
The study was approved by the institutional review boards of the Medical College of Wisconsin and Zablocki Veterans Affairs Medical Center. Subjects were recruited from a group of community-dwelling men and women from southeastern Wisconsin (>60 years of age) participating in a study of body composition changes with age that was funded by the National Institute on Aging. Data on economic status, years of education, smoking, and baseline dietary status have been described elsewhere (32). Excluded from the study were those with symptomatic chronic disease of any organ system other than glaucoma, cataracts, hypertension, treated idiopathic hypothyroidism, and degenerative joint disease. Specific exclusionary criteria were body weight <85% and >120% of ideal, recent weight change of more than 5 pounds, presence of diabetes mellitus, a Folstein Mini-Mental State Examination score below 25, and the use of prescription medications other than antihistamines, non-narcotic analgesics, antihypertensives, and thyroid or hormone replacement therapy. All subjects signed a separate consent form to participate in the dental component of the study and were informed that not participating in the dental/oral component would not influence their participation in the ongoing project.

BMD
Skeletal BMD was measured by dual-energy X-ray absorptiometry (DXA; Norland XR26, Fort Atkinson, WI) at six sites: the proximal and distal radius, the lumbar spine (L2–4), the femoral neck, Ward's triangle, and the intertrochanter region. Measurements were obtained every 6 months over a 5-year period.

Oral Examination
All subjects were examined at the 4-year point of the 5-year longitudinal study. A single investigator (J.H.), blinded to other data (e.g., hormone use and BMD), performed all oral assessments, eliminating the risk of inter-examiner error. Visual inspection and careful digital palpation determined the presence or absence of MT and PT. No distinction was made regarding the size or shape of tori. When applicable, subjects were asked to take out removable dentures before the oral examination.

Salivary Cortisol Levels
Cortisol levels were measured in saliva obtained at 11 PM (nadir in circadian rhythm) and 7 AM (peak in circadian rhythm) at the 4-year point of the study. Subjects collected evening saliva at home and returned the samples for processing on the same day they collected morning saliva. Saliva was sampled by having subjects chew on a cotton roll (Salivette; Sarstedt, Newton, NC) for 2 to 3 minutes or until the cotton roll was soaked with saliva. Saliva was separated from the cotton roll by centrifugation and then frozen. Salivary cortisol concentration was measured by radioimmunoassay as previously described (33). The minimal detectable level was 0.4 nmol/l, and the interassay coefficient of variation was 6% to 12%.

Data Analysis and Statistics
Descriptive statistics, Pearson's correlation coefficients, one-way analysis of variance (ANOVA), repeated measures ANOVA, and categorical ANOVA were performed using Excel 7.0 (Microsoft, Redmond, WA) for personal computers and SPSS for OSF/1, Release 6.1 (SPSS, Chicago, IL) software. A p value of <.05 was considered statistically significant.


   Results
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 Abstract
 Methods
 Results
Discussion
 References
 
A total of 230 subjects agreed to participate in the oral/dental component. There were 129 men (aged 71 ± 4 years, mean ± SD) and 101 women (aged 70 ± 4 years). At study entry, 43 women were on hormone replacement therapy (+HRT) and had been taking estrogen for at least 1 year, and 58 women were not taking HRT (-HRT). +HRT were somewhat younger than -HRT (69 ± 4 years vs 71 ± 5 years; p < .05). Slightly less than 30% of the 230 subjects gave a past history of smoking (n = 68), although fewer than 10% were current smokers. The average length of time smoked was 22 ± 2 years, and the average amount smoked was 27 ± 3 pack years.

Table 1 shows the prevalence of mandibular and palatal tori in this group of men and women. The presence of tori was unrelated to age. The percentage of all subjects with only mandibular tori was 23% (53/230), the percentage with only palatal tori was 12.6% (29/230), and the percentage with both was 12.2% (28/230). MT only were present in 27% of men and 18% of women (not significant). PT only were significantly more common in women than in men (20% vs 7%; {chi}2 = 7.34, p < .01). The presence of tori in both locations occurred in 15.8% of women and 9.3% of men (not significant).


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  		Table 1. Prevalence of Mandibular and Palatal Tori in 230 Elderly Subjects

 
Mean BMD was greater in men than women and greater in +HRT women than in -HRT women at all sites (Table 2 ). This pattern was observed not only at the time of oral examination but throughout the study. Table 3 shows the correlations between BMD and the presence of mandibular tori. For all subjects, the presence of mandibular tori was significantly correlated with BMD at the lumbar spine, femoral neck, trochanter, and Ward's triangle. For -HRT women, the presence of mandibular tori was directly and significantly correlated with BMD at the femoral neck and trochanter site (Table 3 ). Because these subjects had been involved in the longitudinal study for 4 years prior to oral examination, we wished to examine the relationship between the presence of tori and BMD at baseline. For -HRT women, the presence of mandibular tori correlated with BMD at the femoral neck 4 years earlier (r = .33, p < .02). There were no significant correlations between the presence of tori and baseline BMD for +HRT women or for men. No significant correlations were present between BMD of the proximal and distal radius and mandibular tori in any group. Table 4 shows the correlations between BMD and the presence of palatal tori. For all subjects combined, the presence of a palatal torus was inversely related to BMD only at the proximal radius (r = -.144, p = .041) and at the distal radius (r = -.190, p = .007).


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  		Table 2. Mean Bone Mineral Density by Gender and Hormone Use at Year 4 (Phase 8)

 

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  		Table 3. Correlations Between the Presence of Mandibular Tori and Bone Mineral Density at Year 4

 

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  		Table 4. Correlations Between the Presence of Palatal Tori and Bone Mineral Density at Year 4

 
Salivary Cortisol, Tori, and BMD
In men, there was a significant inverse correlation between evening salivary cortisol levels and the presence of a palatal torus (r = -0.21, p = .02). In other words, men with a palatal torus had significantly lower nadir cortisol levels than men without a palatal torus.


   Discussion
Top
 Abstract
 Methods
 Results
 Discussion
References
 
The primary purpose of this study was to investigate the prevalence of tori and the relationship between mandibular and palatal tori, BMD, and adrenal and gonadal hormones in a group of community-dwelling elderly subjects. In this group of initially healthy, predominantly Caucasian men and women over the age of 65, more than 35% were found to have mandibular tori. The prevalence of tori in this population was at the high end of that reported in living populations by other investigators. In these studies, certain ethnic groups displayed high frequencies of tori (Eskimos and Aleuts) compared with low frequencies in Caucasians, African Americans, and Asians (5)(4)(34)(35)(36). Higher frequencies have been reported in studies of skeletal remains, perhaps due to the mode of examination (5)(37). Previous reports also found a higher frequency of palatal tori compared with mandibular tori (4)(34). By contrast, the present study found a higher frequency of mandibular tori with no difference between genders. Palatal tori were more common in women.

As expected, BMD was higher in men than women, and higher in +HRT women than -HRT women. There were significant positive correlations between the presence of mandibular tori and BMD for all subjects and for -HRT women. There was a significant negative correlation between evening salivary cortisol and palatal tori in men. As we have recently described, men with higher salivary cortisol levels had lower BMD (16). The rate of bone loss was similar for all subjects regardless of the presence or absence of tori, gender, or use of HRT. The presence of tori appears to be an indicator of denser skeletal mass in -HRT women and in the group as a whole. The subgroup of +HRT women had significantly greater BMD, and this relationship appeared to override the significance of tori as an indicator of higher bone density. It should be emphasized that these correlations, although statistically significant, were quite low, as would be expected when many other factors are likely to be stronger predictors of BMD.

The underlying etiology of tori remains unclear, and it is also uncertain if mandibular and palatal tori share the same etiology. Little is known about the potential significance of tori for oral or general health. This is the first study to describe a significant relationship between mandibular tori and BMD. Women who were not using HRT who also had mandibular tori had significantly higher BMD at the femoral neck and trochanter. This suggests that the presence of mandibular tori early in life may be of prognostic value for the natural history of BMD loss in women after menopause. The presence of tori in young adulthood may be a marker of higher peak BMD in the future and may possibly indicate a lower risk for developing osteoporosis at more advanced ages. The presence of palatal tori may also predict patterns of cortisol dynamics with aging.


   Acknowledgments
 
This study was supported by NIH/NIA Grant AG 12010-10, the Veterans Affairs Research Service, GCRC Grant M01 RR00058-38, and St. Luke's Medical Center.

We thank Dr. Dale E. Mattson for help with the initial statistical analyses.

Received July 25, 2000

Accepted December 5, 2000


   References
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 Abstract
 Methods
 Results
 Discussion
 References
 

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