OPS2 - Oral Medicine Problems in the Elderly

Question 1

what oral conditions predominantly affects the elderly

Answer 1

○ Lichen planus
○ Mucous membrane pemphigoid
○ Herpes zoster
○ Post herpetic neuralgia
○ Carcinoma
○ Potentially malignant lesions 
○ Sore tongue
○ Candidosis

Question 2

what cardiovascular conditions predominantly affects the elderly

Answer 2

○ Hypertension and ischaemic heart disease
○ Cardiac heart failure
○ Temporal arteritis

Question 3

what respiratory conditions predominantly affects the elderly

Answer 3

• chronic bronchitis and emphysema

- pneumonia

Question 4

what musculoskeletal conditions predominantly affects the elderly

Answer 4

○ Osteoarthritis
○ Osteoporosis
○ Paget’s disease

Question 5

what haematological conditions predominantly affects the elderly

Answer 5

○ Anaemia
○ Chronic leukaemia
○ Multiple myeloma

Question 6

what genito-urinary conditions predominantly affects the elderly

Answer 6

○ Urinary retention
○ Urinary incontinence
○ Prostatic hypertrophy and cancer
○ Renal failure

Question 7

what neurological conditions predominantly affects the elderly

Answer 7

○ Poor vision
○ Multi-infarct dementia
○ Parkinson’s disease
○ Strokes
○ Ataxia
○ Trigeminal neuralgia
○ Alzheimer's disease

Question 8

what other conditions predominantly affects the elderly

Answer 8

○ Nutritional deficiencies
○ Accidents
○ Malignancies

Question 9

what psychological conditions predominantly affects the elderly

Answer 9

○ Insomnia
○ Dependence on hypnotics
○ Loneliness
○ Depression
○ Paranoia
○ Acute confusional states
○ Atypical facial pain

Question 10

what is a haemangioma

Answer 10

• Haemangioma is a collection / malformation of tiny blood vessels
  ○ Bursts the walls of the capillaries and there is this venous leak
• If they are traumatised they will bleed
• They can occur on any site of the mouth but commonly will be found on the inside of the lip or the side of the tongue
  ○ Often will find little bunches (like little bunches of grapes) underneath the tongue
• They can grow to a much greater size than this which makes them much more likely to be traumatised
• If the decision is taken to remove them then it should be done in a hospital because of the risk of bleeding by a specialist oral surgeon
  Now a days we will tend to use something like cryotherapy but still should be done by a specialist surgeon

Question 11

what is the fibroepithelial polyp

Answer 11

• The mucosa of the polyp looks exactly the same as the surrounding mucosa
• What has happened here is that there has been a little bit of trauma and instead of healing itself properly you get this build up of tissue
  ○ But it is exactly the same tissue
• They can become sessile which means they are broad based or they can be on a stalk which makes them a little easier to remove
• When they get to a bigger size it is best to remove them because if they continue to grow they become much more difficult to remove and can become obsolete particularly with teeth
  ○ Can become pressed against the teeth
• Nothing to worry about but best not to let them get too big

Question 12

what is black hairy tongue

Answer 12

• Not as common now
  ○ Perhaps commoner in people who smoke (particularly people who smoked a pipe)
• It is just an extension / overgrowth of the surface of the tongue which picks up stains like tannins from tea or red wines
• It can become quite unpleasant
  ○ Unpleasant to look at
  ○ Can begin to smell a little bit
• Nothing to worry about ~ it is just a variation of normal
• Very difficult to get rid of it because it is part of the surface of the tongue but you can try to clean it from the midline forwards
  ○ Never clean from front to back because you don’t want to scrape the stuff on the tongue down the throat
  ○ Use gentle circular motions with a soft toothbrush but nothing too harsh
  ○ Can even use a tongue scraper to try and remove the excess of this

Question 13

what is geographic tongue

Answer 13

• Erythema migrant is another name for this
  ○ Supposed to look like a map of the world
• About 10% of the population has this ~ it is a variation of normal
  ○ About 10% of this 10% complain that it has a degree of sensitivity meaning it is difficult for them to eat spicy or acidic foods such as tomatoes, lemons and oranges and curry
  ○ But most patients have no problems with this at all
• If you look at the tongue 2 months apart you might find that the appearance is completely different
  ○ Have these areas of atrophy surrounded by white serpiginous margins (slightly raised, snake-like margin)
• Nothing to worry about
  If it is a little bit sensitive you might want to offer some support

Question 14

what is atrophic glossitis

Answer 14

• Really smooth tongue
  ○ Tongues are not meant to be smooth and shiny
  ○ They are meant to be a bit rough and have a light coating on the surface
• This is a really uncomfortable tongue
• Common cause for this is low iron levels or vitamin B12
• If it is allowed to stay like this and the iron levels drop further then the next stage would be ulceration
  ○ This becomes much more difficult to deal with
• If an elderly person presents like this you want to ask their GP to do some routine blood tests for you
  ○ Then depending on what you find you can send this into the oral medicine clinic
  ○ The routine bloods can even be useful for the GP to discover they do actually have really low iron

Question 15

what os frictional keratosis

Answer 15

• End up with a white patch
• Quite easy to see here
  ○ This is a homogenous white patch on the lateral border of the tongue
  ○ Can see the initial trauma and then this keratinisation which has been produced around this site to try and protect that area
• Remember if you cannot scribe a white patch to any particular thing / condition then you have to keep an eye on it and take a biopsy of it
• But with this patient we can see where the trauma is and we can hopefully sort the trauma but we need to go back and check that this white patch has resolved

Question 16

what is speckled leukoplakia

Answer 16

• Hyperplastic candidosis is another name
  ○ More serious
• This is occurring just inside the angle of the mouth and is very speckled
• Can be unilateral, sometimes bilateral
• Much more common in smokers
  ○ Especially pipe smokers
• This is a pre-malignant lesion so it absolutely needs to be followed up
• Initially get a microbiological swab and get an idea of how much candida is actually there
  ○ Then it would have to be biopsied and taken forward from there into the oral medicine clinic or something like that

Question 17

what is sublingual keratosis

Answer 17

• Ventral tongue, lateral border of the tongue and the buccal corridors along the floor of the mouth are common sites for something unpleasant to be
• Can see for this patient that the white patch crosses the midline
  ○ Although it seems much worse on one side than the other
• Something like this you would want to refer onto the experts in the oral medicine clinics to be assessed

Question 18

what is traumatic keratosis

Answer 18

• Although the levels of edentulism are dropping dramatically there are still large numbers of the older population who wear dentures
  ○ Often these dentures are very ill-fitting
• In the top picture there is a white patch in relation to the denture
  ○ When the denture is removed you can actually see the lines the denture runs along
• There is a homogenous wite patch, with tram-lines running through it that correspond exactly to the periphery of that denture
  ○ = traumatic keratosis
• What do we do?
  ○ Take the denture and remove it so there is no pressure on that area
  ○ Review the patient
  ○ White patch should resolve completely
  ○ Then you can rebase the denture if it is good enough to be rebased
  ○ If not then make a new denture to try and avoid this happening again

Question 19

what is denture induced hyperplasia

Answer 19

• Very common in older people
  ○ Particularly the very elderly
  ○ More common with lower dentures than upper dentures
• The lower denture doesn’t fit so it is see-sawing around in the mouth
  ○ End up getting flaps of tissue as the mouth tries to protect itself
  ○ It just keeps laying down more and more tissue
  ○ Creates lots of ridges of tissue and can ulcerate as well so it is very uncomfortable for the patient
• Best way to deal with this initially is to get the denture out of the mouth
  ○ See if some of the tissue will disappear
• Unfortunately when the problem is as long standing as the picture the chances are you are not going to get the tissue to just go
  ○ Depending on how healthy your patient is you can either surgically remove some of the tissue
  ○ Or just cut back the denture quite dramatically so that it is completely area from that area so there is no pressure on this
• These flaps / ridges of tissue created are the same colour and look the same as the other mucosa in the mouth
  ○That is exactly what it is, just trying to protect itself

Question 20

what is denture stomatitis

Answer 20

• Very common and often people don’t know that they have it as it is generally painless
• The thing to notice is that looking into the mouth with a denture in the mouth will appear healthy
  ○ But once the denture is removed you can see the area of erythema corresponds exactly to the fitting surface of the denture
• This happens because this is a candida infection and the candida can burrow onto the surface of the mucosa and burrow into the plastic of the denture
• Important to investigate the patient’s denture hygiene
  ○ Do they always wear their denture?
  ○ How well do they clean it?
• Most important thing is to make sure the patient doesn’t wear their denture at night
  ○ Difficult thing to ask
  ○ Even if the denture can be out for an hour and soaked in a solution of dilute sodium chloride for about 20 minutes and then rinse it and leave it in water for another 20-30 minutes

Question 21

what is angular cheilitis

Answer 21

• This is another type of candida infection, although sometimes it can be a bacterial infection
  ○ Can also be a mixed infection
• This is where you get cracks and lacerations that occur at the corner of the mouth
• Can be very difficult to heal
• If the patient is wearing a denture the most common reservoir of infection for angular cheilitis is inside the mouth
  ○ So again it is important to have good denture hygiene
• Very often there is a staphylococcal element to this
• Very important to deal with the problem before throwing medication at the patient
  ○ Want to check the dentures the patient wears
  ○ Want to check if she is drooling or if the dentures are the reason she is drooling
  ○ Are the dentures causing problems because they are old and poor fitting?
  ○ Take bloods and see if the patient has low iron levels
• Important to remember that with older patient’s their face will start to sag a little bit and you can get skin folds
  ○ Creates a moist, painful area
  ○ Especially if the patient is dependent and is not having their face cleaned and dried properly regularly
  ○ This makes it more difficult to deal with

Question 22

what is xerostomia

Answer 22

• Can be due to many things:
  ○ Conditions like Sjogren’s Syndrome
  ○ Polypharmacy is the most common cause
  ○ Radiotherapy of the head and neck
• Drug induced dryness of the mouth
• Can see this cobblestone fissure defect caused by very long term dryness
  ○ Often seen in patient’s with Sjogren’s Syndrome
  ○ Very uncomfortable and sticky
• A good way to test if the mouth is dry, even if it looks like there is some saliva there is to use the front part of your mouth mirror
  ○ Place it on the tongue and if it sticks that gives you an indication that perhaps the quality of the saliva is not what it should be

Question 23

how is xerostomia managed

Answer 23

• Change medication

• Salivary replacement
○ Saliva Orthana
§ pH neutral and contains fluoride
○ Glandosane
§ This is very acidic
§ Should never be used by people with natural teeth
§ Mouth will already be acidic because it is so dry so why would you add more acidic content to the mouth
○ Biotene Oral Balance
○ BioXtra
○ The problem with these is that their effect is very short lived
○ Patients tend to get fed up with them

• Salivary stimulants
○ Chewing gum
○ Glycerine and lemon
§ This is acidic so don’t recommend this
○ Don’t want the patient chewing so much they are putting strain on the facial muscle and joints

Question 24

what are the 2 main drugs which cause topical drug reactions

Answer 24

Two main drugs are aspirin and iron tablets

But all sorts of other drugs for example like the ones used to treat arthritis as well as more modern drugs

Question 25

how do aspirin burns occur

Answer 25

Patients put the tablet next to the tooth causing pain and hope that as it dissolves away it will also take the pain away But what it actually does is burns the mucosa

Question 26

how do iron tablets cause burns

Answer 26

If they are left in contact with mucosa for any length of time then they will burn that mucosa

Question 27

what sort of tablets should be given to a patient with difficulty swallowing

Answer 27

- So for a patient with difficulty swallowing, maybe because of a dry mouth, should be given liquid iron ○ This is messy and turns everything black but it can be cleaned and it isn't painful ○ Whereas an iron tablet burn can be really uncomfortable and can be dangerous if left

Question 28

what is the difference between lichen planus and lichenoid reactions

Answer 28

``` Lichenoid reactions mimic lichen planus but not a result of an autoimmune condition but occurs as a direct reaction to certain drugs • NSAIDs • β-blockers • Diuretics • Oral hypoglycaemics • Statins • Antimalarials • Sulphonamides The list is endless ```

Question 29

where can lichen planus affect in the mouth

Answer 29

Affecting mainly the buccal mucosa, the tongue and attached gingivae It is rare to get it on the palate (more likely to be a lichenoid reaction than true lichen planus if it presents on the palate)

Question 30

what do bisphosphonates do

Answer 30

* Incorporated in skeleton * Inhibit bone turnover * No repair of microdamage * Anti-angiogenic * So if we take a tooth out, we break the bone that is supporting the tooth (not the cortical bone just the supporting bone) * These are good drugs and patients need to be on these drugs but they just create issues for us for when we go to take teeth out * Common drugs to come across they inhibit osteoclast migration and activity

Question 31

what are the different uses for bisphosphonates

Answer 31

``` • Non-malignant ○ Osteoporosis ○ Paget's disease ○ Osteogenesis imperfecta ○ Fibrous dysplasia ○ Primary hyperparathyrodism ○ Osteopenia ``` ``` • Malignant ○ Multiple myeloma ○ Breast cancer ○ Prostate cancer ○ Bony metastatic lesions ○ Hypercalcemia of malignancy ```

Question 32

what are risk factors for MRONJ / BRONJ

Answer 32

* Extremes of age * Concurrent use of corticosteroids * Systemic conditions affecting bone turnover * Malignancy * Coagulopathies, chemotherapy, radiotherapy • Duration of therapy ○ Maximum 3 years now ○ Previously patients were on these drugs for a very long time • Previous diagnosis of BRONJ ○ Ie taking tooth out on the other side • Potency of drug ○ If given intravenously instead of oral the risk increases dramatically • Invasive dental procedures ○ Some form of surgery eg extraction of a tooth or raising a flap ○ Not just an injection for an MOD amalgam • Denture trauma ○ If you have fine mucosa and the denture is rubbing against it ○ Consider putting a soft base on these dentures * Poor oral hygiene * Periodontal disease * Alcohol or tobacco use * Thin mucosal coverage

Question 33

What does the patient need to be told about BRONJ

Answer 33

• Advise patient of BRONJ risk ○ Tell them that the risk is low • Informed consent • Emphasise rarity of condition ○ Rare occurrence of oral drugs • Don't discourage from taking medication • Doesn’t mean we don’t do dental treatment ○ Ie if a tooth needs to come out then that tooth comes out

Question 34

what patient adivce is given to MRONJ patients

Answer 34

* Regular dental checks * Maintain good oral hygiene * Limit alcohol and stop smoking * Report any symptoms (e.g. loose teeth, pain, swelling)

Question 35

what is herpes zoster (shingles)

Answer 35

- Reactivation of varicella-zoster virus which leads to shingles - It can affect any part of the trigeminal nerve in the face - Usually unilateral and in older people ○ Less common in younger people - Rash can appear on the face and in the mouth Very painful

Question 36

what is post herpetic neuralgia

Answer 36

· Previous episode of shingles · Constant burning sensation in dermatomal distribution ○ Can affect any part of the body or the face · Resolves within 2 months in 50% · May persist for two years or longer · Suicide risk ○ Because of the level of pain ~ it is un-remitting · Incidence possibly reduced by antiviral therapy ± steroids · Not very common

Question 37

how is post herpetic neuralgia treated

Answer 37

· Antidepressants ○ Because the patients get so unhappy with the level of pain · Gabapentin · Carbamazepine · Topical capsaicin 0.025% · Transcutaneous electrical nerve stimulation (TENS) ○ Some people find this really helpful, others don’t notice a difference - This condition does affect people psychologically because it is so unremitting and uncomfortable

Question 38

what is trigeminal neuralgia

Answer 38

- 3 branches of the nerve ○ More common in maxillary and mandibular branches - Extreme pain like an electric shock Anything can trigger the pain

Question 39

what is the medical management of trigeminal neuralgia

Answer 39

· carbamazepine ○ Only drug licensed properly for use for this ○ Would want to do baseline bloods and check liver function ○ Start low and gradually build to get the patient pain free in 2-3 days hopefully · Oxcarbazepine · Gabapentin · Pregabalin · Lamotrigine · Sodium valproate · Phenytoin

Question 40

what is the surgical management for peripheral procedures of trigeminal neuralgia

Answer 40

· Cryotherapy · Injection of alcohol or glycerol · Neurectomy · Avulsion of nerve · If a patient presents with a new trigeminal neuralgia you want to request an MRI for that patient and ask if they can look specifically for impingement of the nerve · Older patients do tend to cope well with the surgical management ○ Especially if it means they don’t have to take medication constantly · All of these procedures are pretty successful

Question 41

what is the surgical management for ganglion procedures of trigeminal neuralgia

Answer 41

These are much more complicated and would be done by the neurologists · Balloon compression · Radiofrequency - thermocoagulation · Alcohol or glycerol injection · Microvascular decompression · Gamma knife radiosurgery ○ Only available in one site in England

Question 42

what needs to be considered with trigeminal neuralgia

Answer 42

• Multiple sclerosis • Space occupying lesion Especially consider this in a younger patient Very important to have the appropriate tests or to have the patient appropriately referred

Question 43

what is burning mouth syndrome

Answer 43

* More common in females (F:M = 3:1) * +/- anxiety * +/- depression • No cause identified in 50% patients ○ Mouth has a healthy appearance but patient is suffering from this intense burning sensation * Psychogenic in 20% * Drugs (ACE or protease inhibitors) * Dry mouth * Candidosis • Haematinic deficiencies ○ Anyone with burning mouth syndrome will automatically have full blood count • Diabetes • Parafunctional activity ○ Check if the patient is holding their dentures in by clenching their teeth together ○ Or is the patient grinding their teeth all night • Denture factors ○ If it doesn’t fit properly or if it is moving all the time • Hypothyroidism • Allergy ○ Rare but does happen • May lead to malnutrition ○ Because it is such an uncomfortable condition • Slow rehabilitation • Slow recovery ○ Sometimes patients never recover * Reduce quality of life * Patients need to be reassured that it is not cancer ~ educate • However they do have something sending messages to their brain saying their mouth is burning even though there is nothing to see ○ The more people who tell them there is nothing to see the more anxious they become • There is no bottle / spray they can get that will cure the burning mouth syndrome ○ Will just irritate the mouth more because of the chemicals in it

Question 44

what are conservative measures of treating burning mouth

Answer 44

• Conservative measures: ○ Anti-stress ○ Mindfulness ○ Relaxation ○ Reassurance ○ Certain drugs might help but they are not a cure § They will just dampen down the messages to the brain but they don’t take it away completely § Can also cause dry mouth so it can just feed into the cycle / circle of symptoms • Stress and anxiety is a huge part of it for many patients

Question 45

how can oral cancer be diagnosed early

Answer 45

- Oral mucosal screen is something we do as part of our general first time oral examinations ○ Learn how to do it ○ Have a system and do it the same way - Want to make sure lesions are not missed - Better to be picked up at an early stage ~ more treatment options

Question 46

why is it better to diagnose oral cancer earlier

Answer 46

When it prevents advanced there may not even be treatment options available and if there are then the treatment is not going to be very pleasant Needs to be operable