Geriatric Oral Health

Question 1

why geriatric oral health matters?

Answer 1

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.

Question 2

Geriatric Assessment Goals

Answer 2

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

Question 3

Oral Pain Assessment

Answer 3

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

Question 4

Face/Lip Exam

Answer 4

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.

Question 5

Gum/Teeth Exam

Answer 5

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)

Question 6

age related changes

Answer 6

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.

Question 8

dental implants

Answer 8

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.

Question 9

Dentures/Bridges

Answer 9

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

Question 11

Mucosal Assessment

Answer 11

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.

Question 12

Tongue Assessment

Answer 12

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.

Question 13

Denture Complications

Answer 13

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.

Question 14

Denture Stomatitis

Answer 14

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.

Question 16

Denture Care

Answer 16

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

Question 17

Caries

Answer 17

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

Question 18

Risk Factors of Caries

Answer 18

• 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

Question 19

Tx of Caries

Answer 19

• 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

Question 20

Describe Silver Diamine Fluoride for Caries

Answer 20

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

Question 21

Gingivitis

Answer 21

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

Question 22

Periodontitis

Answer 22

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.

Question 23

Leukoplakia/Erythroplakia

Answer 23

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.

Question 24

Oral Cancer

Answer 24

Symptoms
* Red or white patches persisting beyond two weeks
* Ulcers that are non-healing or bleed easily
* Masses

Ninety percent of oral cancers are squamous cell cancers of the mucosa. If a red or white patch appears and does not resolve, suspect leukoplakia (precancer) or cancer and pursue biopsy of the lesion. The development of a mass or ulcer is a late sign with poorer prognosis.

Etiologies
* Human Papilloma Virus, HPV 16: accounts for the rising incidence or oral cancers, particularly the posterior pharynx, tonsils and the base of the tongue; Especially in younger individuals, 40-64; HPV vaccine may decrease rates of oral HPV infection

Treatment
* Evaluation by a specialist for any mouth lesion that won’t heal or bleeds easily; persistent lump or soreness in the mouth, throat, or tongue; or difficulty chewing or swallowing
* Biopsy of suspicious lesions
* Surgical resection, lymph node dissection, radiation, or chemotherapy are all treatment options depending on clinical stage and location

Question 25

Nutrition & Geriatric Oral Health

Answer 25

Tooth loss, dentures, and decreased saliva can lead to alteration in diet. Elders may experience the following:

• Changed sensory perception of eating (texture and taste)
• Lowered chewing efficiency
• Decreased intake of important nutrients
• Less fresh fruit, vegetables, and fiber in the diet
• Less Vitamin C and beta carotene
• Compensatory habits such as sucking mints or consuming sweetened beverages to mitigate dry mouth, which may result in: empty calories or increased caries risk

Question 26

link between DM and peiodontal disease

Answer 26

Poor glycemic control in patients with diabetes increases the risk of periodontal disease and periodontal disease worsens glycemic control in a vicious cycle.

Question 27

Osteoporosis/necrosis

Answer 27

Patients with osteoporosis may experience oral changes, such as:
* Increased tooth loss
* Additional denture adjustment as jaw shape changes

Osteonecrosis
* IV bisphosphonates are associated with osteonecrosis of the alveolar bone
* Prevalence is rare, at approximately 0.1%
* Can occur at the site of a tooth extraction or spontaneously
* American Dental Association recommends regular dental care for patients on bisphosphonates
* Discontinuing bisphosphonates may not lower the risk, but may negatively impact low bone mass treatment

Symptoms of Osteonecrosis
* Jaw pain
* Swelling and infection
* Loosening teeth
* Drainage and exposed bone

Question 29

Aspiration Pneumonia

Answer 29

Aspiration of oral bacteria is associated with pneumonia, particularly in bedridden and hospitalized patients. Consider the following:
* 83% of patients who develop nosocomial pneumonias are mechanically ventilated.
* Oral care protocol interventions led to an 89.7% reduction in ventilator associated pneumonia.
* Oral hygiene strategies in hospitalized and nursing home populations also can reduce the incidence of pneumonia.

Question 30

Vascular Disease & Oral Health

Answer 30

Periodontal disease is associated with coronary artery disease and cerebrovascular disease
* Studies support an association between PD and ASVD, but not a causative relationship.
* Inflammatory cytokines implicated in atherogenesis are produced in patients with periodontal disease.
* Treatment of periodontal disease has not been shown to date to reduce cardiovascular risk.

Strokes can result in multiple oral problems, such as:
* Oral sensory and motor deficits
* Poor tongue function and lip seal
* Dysphagia
* Reduced oral clearance of foods and increased food packing
* Reduced dexterity negatively affecting ability to perform oral hygiene
* Increased caries and periodontal disease risk

Question 31

RA & Oral Health

Answer 31

An inter-relationship exists between oral health and rheumatoid arthritis (RA). Periodontal disease is more common in patients with RA, and treatment of periodontal disease may reduce severity of RA.

Rheumatoid Arthritis can result in multiple oral problems, such as:
* Diminished ability to chew and eat if RA involves the temporomandibular joint
* Diminished salivary output (Sjögren’s Syndrome), leading to xerostomia and caries
* Reduced dexterity, which affects ability to perform oral hygiene
* Increased caries and periodontal disease risk

Question 32

Dementia & Oral Health

Answer 32

Pts w/ dementia have increased risk for caries, periodontal disease, and oral infections.

Contributing factors to oral problems include:
* Self-care deficits
* Chronic disease burden
* Dietary changes
* Difficulty complying with: Medications, Oral hygiene, Dental appointments
* Dependence on caregivers
* Behavioral changes
* Postural impairments
* Swallowing difficulty
* Lack of understanding leading to resistance to care

Question 33

Med Side Effects:
* Phenytoin, methotrexate, CCBs
* IV Bisphosphonates
* Chemo/Rad
* Steroids
* Nifedipine (T2 DM)
* Sugar containing meds
* Progesterone, nitrates, BBs, CCBs
* Anti-HTNs, Anti-depress, Anti-hista, diuretics

Answer 33

• Phenytoin, methotrexate, CCBs: gingival hyperplasia
• IV Bisphosphonates: osteonecrosis
• Chemo/Rad: stomatitis, mucositis
• Steroids: candida
• Nifedipine (T2 DM): periodontal dz
• Sugar containing meds: dental caries
• Progesterone, nitrates, BBs, CCBs: dental erosions due to GERD
• Anti-HTNs, Anti-depress, Anti-hista, diuretics: xerostomia

Question 34

define xerostomia

Answer 34

Xerostomia is the sensation of dry mouth due to decreased salivary flow, and is common in the elderly. Saliva acts as a lubricant for the oral cavity, promotes remineralization of teeth to prevent decay, and protects against fungal and bacterial infection. Saliva is also the most important protection against caries. Xerostomia significantly increases the risk of caries and periodontal disease.

Question 35

Managing Xerostomia

Answer 35

Avoid using these products:
* Inciting medications
* Irritants such as alcohol, caffeine, and tobacco
* Sugar-containing drinks and candies

Suggest patients do the following:
* Take sips of water, especially during eating.
* Chew sugarless gum and mints.
* Use saliva substitutes.
* Try salivary stimulants such as pilocarpine.

Prevent caries and periodontal disease by:
* Maintaining meticulous oral hygiene
* Using increased strength topical fluorides such as 1.1% sodium fluoride

Question 36

describe dysgeusia (taste alteration)

Answer 36

Taste alteration (dysgeusia) is associated with over 200 drugs and can have a major impact on quality of life. This side effect is often overlooked by clinicians.

Problems
* Taste may be decreased, altered, or made unpleasant.
* Taste alteration can lead to weight loss and depression.
* People may compensate with sugared foods, which can lead to caries.

Most common offending classes of medications are antibiotics, antifungals and antivirals, cardiac medications, chemotherapy agents, Parkinsonian and migraine agents, thyroid medications, and psychotropics.

Non-medication causes of taste alteration include:
* Upper respiratory illnesses
* Other viral infections (Influenza, Coronavirus)
* Radiation therapy
* Exposure to chemicals or insecticides
* Previous otolaryngological surgery
* Sjogren’s syndrome or other rheumatological conditions