Geriatric Oral Health Flashcards
why geriatric oral health matters?
Geriatric oral and systemic health are tightly interconnected:
* Poor oral hygiene is associated with increased incidence of pneumonia.
* Many medications cause dry mouth, increasing risk of dental caries.
* Diabetic glucose control and periodontal disease directly interplay, with poorer diabetes control worsening periodontal disease and vice versa.
* Poor oral health can cause weight loss and failure to thrive.
Health care professionals of all types can play an important role in improving the overall health of their patients by addressing oral issues.
Geriatric Assessment Goals
Assess symptoms suggestive of oral problems
Examine:
* Face and lips
* Teeth, gums, and dentures, including level of hygiene
* Mucosal surfaces, including the soft and hard palate, and saliva levels
* Lateral borders and undersurface of the tongue
* Posterior pharynx
Palpate:
* Neck
* Temporomandibular joint
* Floor of the mouth
* Identify abnormal lesions
* Offer anticipatory advice
Oral Pain Assessment
Oral pain is common
* Almost ¼ adults report oral pain in the past year
* Pain may be vague and poorly localized
Communicating pain is often difficult for those with disabilities and non-verbal adults:
* May be agitated, refuse to eat, pull at the face
* May see cheek or gum swelling, broken, decayed or loose teeth, ulcers, abscesses or fistula on exam
Consider abuse with visible trauma
Face/Lip Exam
Examination
* Examine face with lips at rest.
* Identify facial deformities, as well as skin or peri-oral lesions.
Common Abnormalities
* Squamous cell carcinoma of the lip may present as a dry, scaly, or ulcerated non-healing lesion.
* Creasing of facial skin at either corner of the lips is often due to tooth loss or poorly fitting dentures that do not restore vertical height and may predispose patient to angular cheilitis.
Gum/Teeth Exam
Examination
* Remove dentures
* Check hygiene status
* Assess for: caries, root caries, gingivitis, periodontal disease
Common Abnormalities
* Cracked or missing teeth
* Tooth decay
* Signs of gum disease (Exposed roots, Erythema, Inflammation, Bleeding)
age related changes
With age, teeth can become darker or more yellow in appearance. Enamel thins allowing the naturally darker dentin layer to show through more prominently.
Teeth begin to wear down with age (also known as attrition), and may stain when exposed to nicotine and coffee. However, with diligent oral care, older adults can maintain a nice smile.
dental implants
Dental implants are surgically placed into the jaw and then usually crowned.
Implants are also used to retain dentures in patients who are edentulous. Dentures can be made to fit over two to four implants in the upper or lower jaw to enhance denture retention and stability.
Some patients may ask their primary care clinician whether they should have dental implants placed. For patients with a healthy mouth, a history of good oral hygiene, and few medical problems, this is likely a straightforward procedure.
Patients with decreased jaw bone mass (i.e., osteoporosis, low hanging maxillary sinus, or bone resorption from an extraction site), diffuse caries, or difficulty with hygiene due to other medical co-morbidities may not be good candidates for dental implants.
Implant placement is contraindicated in patients who have received IV bisphosphonates. Poorly controlled diabetes or serious bleeding disorders are also a concern.
Dentures/Bridges
Dentures
Removable dentures may be complete (replacing all teeth) or partial (replacing some teeth). They should be removed during the oral examination and assessed for:
* Fit
* Comfort
* Broken areas
* Missing prosthetic teeth
Bridges
Fixed bridges may replace one or more teeth and are connected to adjacent healthy teeth using a crown. A bridge cannot be removed. Teeth serving as retention for partial dentures or attachments for bridges may be:
* More difficult to clean
* Prone to caries and gum disease
Mucosal Assessment
Examination
* Mucosa should appear wet and glistening. Pay particular attention to mucosa under dentures.
* Inspect lateral margins and undersurface where disease changes often occur
Age-Related Changes
* Aging results in thinning of oral mucosa and decreased elasticity.
* Dry mucosa interferes with denture retention and lack of saliva increases risk of caries.
Tongue Assessment
Examination
* Grasp tip of tongue with gauze to pull forward and up.
* Inspect lateral margins and undersurface where pathological changes often occur.
Age-Related Changes
* Fissuring, mucosal thinning, and sublingual varicosities are common.
* Although number of taste buds decreases with aging, diminished taste sensitivity is more likely due to smoking, drugs, and dry mouth.
Denture Complications
Ulceration
Ulcerated mucosa from denture irritation is caused by:
* Ill-fitting dentures
* Poor hygiene
* Dentures left in too long
Angular Cheilitis
Angular cheilitis is common when old dentures have insufficient vertical height leading to skin creasing at the corners of the mouth. Clinicians should:
* Assess dentures and the need for them to be remade or relined.
* Treat with topical antifungals for two weeks.
* Perform a biopsy if lesions do not heal.
Denture Stomatitis
Symptoms
* Erythema of palate with cobblestoning of mucosa
* Often asymptomatic
Etiology
* Complex and multifactorial, but Candida plays a major role
* Most prominent risk factor is continuous denture wearing
* Other risk factors include:
* Xerostomia
* Diabetes or immunosuppresion
* Nutritional deficiencies
Treatment
* Treat mouth with topical antifungals for two weeks.
* Soak dentures in chlorhexidine or nystatin
* Dentures should be out of the mouth for at least eight hours each night.
* Caution: Chlorhexidine may stain teeth yellow to brown, alter taste temporarily, increase deposition of calculus (tartar), and the taste may be unpalatable.
Denture Care
Overnight, saliva decreases and bacterial counts increase. As a result, continuous denture wear may lead to denture stomatitis, redness, and irritation of the palatal tissues.
Poor hygiene of dentures also contributes to denture stomatitis. Plaque and calculus collect on dentures just as on natural teeth.
Dentures should be:
* Removed at night to let oral tissue rest
* Brushed with liquid hand soap, dishwashing liquid, or denture cleaning paste—avoid using regular toothpaste because it may damage the finish and make it more difficult to clean
* Soaked overnight in a cup of water or denture cleaner
* Examined by a dentist at regular visits
Caries
Etiology
* Dietary carbohydrates are metabolized by bacteria into acids which destroy tooth structure.
* Root caries is common in the elderly.
* Gingival recession exposes susceptible root surfaces.
* Root caries progresses rapidly.
* Left untreated, caries can cause pain, infection, difficulty eating, and tooth loss.
Symptoms
* Mild disease is often asymptomatic
* Pain with eating, temperature change, or spontaneously
Complications
* Cellulitis
* Abscess
Risk Factors of Caries
- High oral bacterial counts
- Frequent consumption of sugar-containing foods
- Inadequate fluoride exposure
- Low socioeconomic status
- Xerostomia related to medications or disease
- Physical disabilities and dementia
- Brushing and other oral hygiene activities become more difficult
- Existing restorations or appliances
- Recurrent caries common at site of existing restoration
Tx of Caries
- Removal of decayed tooth structure and replacement with dental restorative material, usually composite (white) or amalgam (silver)
- Root canal therapy or extraction of the tooth if decay has progressed into the pulp of the tooth
- Extraction is not without consequences. It may result in spacing issues, drifting of the retained teeth, and malocclusion of the neighboring tooth
Describe Silver Diamine Fluoride for Caries
Silver Diamine Fluoride (SDF) is FDA approved as a desensitizing agent, but has “breakthrough therapy status” which facilitates its use in clinical trials. SDF may be indicated in older adults for caries management who have physical or cognitive limitations that prevent conventional restorative or invasive dental treatment (endodontics or extractions). SDF is a topical application which when applied every six months, arrests 91% of carious lesions within two years. The University of California San Francisco School of Dentistry has published a protocol for the use of SDF for caries management.
- Disease control for lesions in high-caries-risk patients at the diagnostic visit, regardless of the restorative plan
- Difficult to treat carious lesions, such as furcations (areas where 2 or more roots meet, usually below the gum line but sometimes exposed due to periodontal disease and attrition) and crown margins
- Patients with extreme caries risk (eg experiencing xerostomia from cancer treatments)
- Individuals who cannot cooperate due to Alzheimer’s disease or other forms of dementia, Parkinson’s disease and other neuropsychiatric challenges
- Patients living in nursing homes and other residential facilities with limited mobility and/or ability to seek care
- Individuals without insurance benefits and/or living on fixed incomes
Gingivitis
Gingivitis is characterized by inflammation of the gingiva without destruction of the periodontal ligament or bone, which distinguishes it from periodontitis.
Symptoms
* Mild gum swelling
* Tenderness
* Erythema
* Bleeding gums
Etiology
* Plaque builds up due to poor oral hygiene.
* Changes in hormone levels can modify the gingival response to plaque, resulting in increased gingivitis.
* Oral foreign bodies such as popcorn kernels are a frequent culprit in acute gum inflammation.
Preventive Measures & Treatment
* Good home hygiene including frequent brushing and flossing
* Regular dental visits to remove plaque accumulation and reinforce appropriate home care
Periodontitis
Periodontitis is the leading cause of tooth loss in adults. Most adults are affected to some degree: 91% of those 79 years of age and older have some degree of periodontal disease.
Etiology
* Chronic plaque exposure causes inflammation which leads to:
* Destruction of periodontal ligament
* Loss of supporting bone
* Tooth loosening and loss
* The body’s host response to the bacteria, magnifying or suppressing the inflammatory response, helps determine the manifestation and progression of the disease.
* Smoking, diabetes, HIV, pregnancy, and poor oral hygiene can all contribute to the development of periodontitis
Preventive Measures & Treatment
* Encourage good oral hygiene and regular dental visits.
* Recommend cessation of tobacco and other irritants, such as cannabis.
* Make a dental referral for deep root scaling.
* Prescribe oral antibiotics and topical solutions such as chlorhexidine.
* Caution: Chlorhexidine may stain teeth yellow to brown, alter taste temporarily, increase deposition of calculus (tartar), and the taste may be unpalatable.
Leukoplakia/Erythroplakia
Oral leukoplakia, the best-known pre-malignant oral lesion, is defined as “a white patch or plaque that cannot be characterized clinically or pathologically as any other disease.” Analogous red lesions are called erythroplakia. Combined red and white lesions are also known as speckled leukoplakia or erythroleukoplakia.
Etiology: usu premalignant
Symptoms
* Leukoplakia and erythroplakia are often subtle and asymptomatic.
* Lesions begin as a subtle white or red patch.
* Progression may lead to slightly elevated plaques that ulcerate.
* Lesions with ulceration are more likely to be cancerous.
* Erythroplakia and speckled leukoplakia are more likely to exhibit dysplasia or carcinoma upon microscopic examination.
Treatment
* All unexplained white lesions persisting for more than two weeks should be biopsied.
* Dysplastic lesions should be removed.
* Cryotherapy and laser ablation have been used, although these methods do not allow for tissue preservation and microscopic examination.
