Oral and Dental in the Elderly Flashcards
What do we do for the extraoral exam?
Palpate lymph nodes, palpate thyroid, look for asymmetry, look for skin/lip lesions
What to we do for the intraoral exam?
Identify: Swellings (diffuse vs. nodules) Ulcers White/red lesions Tooth-related problems (decay, abscess, fracture)
What strucutres do we examine intraorally?
Lips Gingiva Palate FOM Buccal mucosa Tongue Throat
What do we look for in a dental exam?
Fractured teeth
Dental Abscess
Decayed teeth
What are common oral and dental problems?
Infectious
Trauma-related
Medication-related
Mucosal abnormalities
What are common infectious diseases in the mouth?
Root caries, periodontal disease, candidiasis
What are common trauma related diseases in the mouth?
Epulis fissuratum, ulcers, hyperkeratosis
What are common medication related issues with the mouth?
Xerostomia, gingival hyperplasia, lichenoid reactions, ulcers, jaw necrosis
What are common mucosal abnormalities of the mouth?
Leukoplakia, erythroplakia, squamous cell carcinoma (SCCA)
What is the etiology of Root Carries?
Gingival recession & attachment loss
Bacteria
Diminished manual dexterity
Decreased saliva leads to an acidic environment and thus demineralization
What are the common bacteria that cause root carries?
Streptococcus mutans
Lactobacillus acidophilus
Actinomyces viscosus
How do root carries present?
Exposed root surfaces
Yellow, brown or black lesions on roots
Loss of tooth structure
What is the prevention management for root carries?
Fluoride!
Mouthwashes (ACT)
Varnish (applied at dental visits)
Excellent home care & regular dental visits
What is the restoration treatment for root carries?
Resin-modified glass ionomer
Bonds to tooth
Esthetic-tooth colored
Releases fluoride
What is the etiology of peridontal disease?
Poor oral hygiene
Disease-causing bacterial flora (mainly gram -)
Underlying systemic factors & immunosuppression
Progressive inflammation of soft tissues leads to loss of the bone and thus tooth loss
How does peridontal disease present?
“Long in the tooth”
Loss of gum tissue and bone support
Teeth become loose
What is the management of peridontal disease?
Professional deep cleaning (scaling and root planing)
Improved oral hygiene
Chlorhexidine rinse (Peridex)
Severe cases may require periodontal surgery or tooth extraction
What causes candidiasis?
Candida albicans
What are the types of candidiasis?
Pseudomembranous candidiasis (white)
Erythematous candidiasis (red)
Angular cheilitis
Denture stomatitis
What causes pseudomembranous candidiasis?
Abx, immune system dysfunction
What causes erythematous candidiasis?
Abx, xerostomia
What causes angular cheilitis?
decrease in vertical dimension
What causes denture stomatitis?
wearing dentures continuously
How do we treat candidiasis?
Antifungals:
- Clotrimazole (Mycelex), 10 mg, dissolve 1 troche on tongue 5x/day for 2 weeks
- Nystatin (tablet or rinse)
How do we treat angular cheilitis?
Athlete’s foot cream (Lotrimin, Tinactin)
How do we treat denture stomatitis?
Clean denture
Soak in OTC cleanser (Efferdent, Polygrip)
What is the etiology of Epulis Fissuratum?
Tumor-like hyperplasia of fibrous CT
Response to ill-fitting denture
What is the presentation of epulis fissuratum?
Firm, mucosal-colored folds in vestibule
What is the management of epulis fissuratum?
Surgical excision
Fix denture for proper fit
–Re-line or new denture
What is the etiology of traumatic ulcers?
Mechanical damage
Repeated trauma causes ulceration of surface
Accidental biting, sharp teeth, sharp foods, etc
How do traumatic ulcers present?
Most common on tongue, lips, & buccal mucosa
Removable, yellow membrane with a rolled white border and surrounding redness
What is the management of traumatic ulcers?
- Remove irritating source
- Palliative
- Salt-water rinses
Local anesthetic rinse (Dyclonine HCl )
Hydroxypropyl cellulose films (Zylactin B) - Can resemble squamous cell carcinoma! (SCCA)
- If present for longer than 2 weeks, advise referral to dentist/ENT/oral surgeon for biopsy
What is the etiology of traumatic hyperkeratosis?
Repeated trauma causes thickened layer of keratin
Biting/chewing habit, toothbrush trauma, tooth loss
How does traumatic hyperkeratosis present?
Thickened, white patch
Tongue, buccal mucosa, gingiva
Common on edentulous areas
What is the treatment for traumatic hyperkeratosis?
Biopsy often necessary to rule out pre-cancerous lesions (dysplasia)
Discontinue any habit
Smooth or extract sharp/broken teeth
What is xerostomia?
dry mouth
What are the causes of xerostomia?
- Water/metabolite loss (Impaired fluid intake, Hemorrhage, V/d)
- Iatrogenic (Meds, Rxt therapy to H&N)
- Local factors (smoking, mouth breathing, decreased mastication)
- Systemic diseases (Sjogren’s synd., DM)
How does xerostomia presentation in the geriatric population?
25% of geriatric patients
Side effect of 2/3 of most commonly prescribed drugs
What can develop from xerostomia?
Can lead to caries or candidiasis
What might xerostomia cause? (symptoms)
Burning, discomfort, difficulty speaking, difficulty swallowing, decreased ability to taste
What drug classes commonly cause xerostomia?
Antianxiety Antidepressant Bronchodilators Diuretics Antihistamine Antihypertensive Antinflammatory Muscle relaxants Narcotic analgesics Sedatives
How does xerostomia present?
Tongue surface appears dry & may be fissured
No pooling of saliva in floor of mouth
Gloves may stick to oral mucosa
Saliva is thick and ropey
What is the management for xerostomia?
Difficult & unsatisfactory
Artificial saliva
Stimulants (sugarless candy, medications)
Biotene (OTC rinse, toothpaste, gel)
Consider switching medications
Fluoride to prevent decay
Chlorhexidine (Peridex) to minimize plaque
What is gingival hyperplasia?
Overgrowth of gingival tissue secondary to medication
What are the common causes of gingival hyperplasia?
Calcium channel blockers Amlodipine, nifedipine Cyclosporine Anticonvulsants Phenytoin (Dilantin)
What is the treatment for gingival hyperplasia?
Discontinue or switch medications if possible
Chlorhexidine
Frequent professional cleanings & excellent home care
Surgical excision
What is the etiology of a lichenoid drug reaction?
Allergic reaction to medication
Often appear 6 months - 1 year after starting drug
How does a lichenoid drug reaction present?
Clinically identical to true lichen planus
Ulcers with white radiating striae at periphery
Buccal mucosa, tongue, lips
May have superimposed candidiasis
What are some drugs that can cause a lichenoid drug reaction?
NSAIDS (Ibuprofen, naproxen, indomethacin) Beta blockers (Propranolol) Diuretics (Furosemide, HCTZ) ACE Inhibitors (Lisinopril, captopril)
What is the treatment for a lichenoid drug reaction?
Switch or discontinue medication if possible
Topical corticosteroids (Lidex, clobetasol)
–Steroid often ineffective if medication is continued
–Chlorhexidine to prevent candidiasis while on steroid
Mycelex or Nystatin if fungal infection present
What is a fixed drug reaction?
Allergic reaction to medication that recurs at the same site
What are common medications that cause a fixed drug reaction?
Barbiturates
Analgesics/antipyretics (Phenazone derivates, salicylates)
Antibiotics (dapsone, tetracycline, sulfa drugs)
How does a fixed drug reaction present?
Similar appearance to traumatic ulcers
May affect any mucosal surface, often lip & tongue
How does a fixed drug ulcer present? What do you do?
May clinically mimic malignancy
Biopsy often necessary to rule out carcinoma
What is the treatment of a fixed drug reaction?
- Switch or discontinue medication if possible
- Topical steroids (Lidex, clobetasol)
Often ineffective if medication is continued - Palliative treatment
Salt-water rinses
Local anesthetic rinse (Dyclonine HCl )
Hydroxypropyl cellulose films (Zylactin B)
What is a Osteochemonecrosis of the jaw?
Bisphosphonate related osteonecrosis of jaws (BRONJ)
What is the etiology of an osteochemonecrosis of the jaw?
Osteoclast-inhibiting medications prevent normal bone remodeling
Results after trauma or tooth extraction
What are common medications that cause a osteochemonecrosis of the jaw?
IV bisphosponates (Zometa) Oral bisphosphonates (Fosamax, Boniva, Reclast) Monoclonal antibodies (denosamab/Prolia)
What is the presentation of an osteochemonecrosis of the jaw?
Exposed, necrotic bone with surrounding inflammation
May be asymptomatic or painful
What is the treatment for an osteochemonecrosis?
Depends on stage, but generally: Chlorhexidine rinse Systemic antibiotics Surgical debridement Avoid elective dental surgery Review indications for continued therapy
What is leukoplakia?
“White patch” in the mouth
Strictly a clinical diagnosis
Must exclude other entities
Biopsy often necessary
What are key factors about leukoplakia?
Considered precancerous lesion 20% will be dysplastic or malignant Most common oral pre-cancer Most common over 40 years of age Male predominant
What is the etiology of leukoplakia?
Exact cause unknown Tobacco use >80% of pts with leukoplakia are smokers Heavier smokers have increased number & larger lesions UV radiation Lesions on lower lip
How does leukoplakia present?
White appearance results from thickened surface keratin
90% with dysplasia or cancer found on:
Tongue (ventral/lateral), lip vermillion, floor of mouth
Defined white patch, Slightly raised and Fissured surface in a High risk location
What are the progressive clinical changes of leukoplakia?
Thin plaques then thick, fissured raised lesions
May develop red patches=erythroleukoplakia
Where are you most likely to find leukoplakia?
Most common on lip vermillion, buccal mucosa, gingiva
What is the treatment of leukoplakia?
Biopsy, then definitive diagnosis directs treatment
Moderate dysplasia or worse mandates complete removal
Recurrence likely, especially for thick lesions
–Long-term follow-up is required
5% progress to SCCA
What is erythroplakia?
“Red patch”, another strictly clinical diagnosis
Almost all are dysplasia or carcinoma
What is the etiology of erythroplakia?
Exact cause unknown
Presumed to be the same as those for oral SCCA
Who is more likely to develop erythroplakia?
Disease of middle-aged or older adults
Men & women affected equally
What is the presentation of erythroplakia?
Well-demarcated, asymptomatic, erythematous plaque with soft texture
May have nearby leukoplakia
Where are the most common sites of erythroplakia?
Most common sites:
Floor of mouth
Tongue (ventral/lateral)
Soft palate
What is the treatment of erythroplakia?
Biopsy is mandatory!
Moderate dysplasia or worse should be completely removed
Recurrence is common & long-term follow-up is necessary
What is a rule of thumb in regards to dental diseases/conditions and their regression?
If it doesn’t regress within two weeks, refer to dentist/oral surgeon/ENT for biopsy
In the mouth, what should you be suspicious of and where?
Be suspicious of red or white lesions in the following areas:
Ventral & lateral tongue
Floor of mouth
Soft palate
What is the prevelance of oral squamous cell carcinoma?
Oral SCCA make up 3% of all cancers in US
8th most common in males, 15th in females
95% of oral malignancies are SCCA
What is the etiology of oral SCC?
Multifactorial Tobacco & alcohol Human papilloma viruses (HPV) Radiation, immunosuppression Heredity is NOT a cause
How does oral SCC present?
Most are preceded by a precancerous lesion
Erythroplakia or leukoplakia
Pts are usually older men
Minimally painful during early stages!!
Where is oral SCC most likely to develop?
Lateral/ventral tongue
Floor of mouth
Soft palate
What is the relationship between HPV and SCCA?
HPV implicated in up to 90% of oropharyngeal SCCA
Responsible for almost all oral SCCA in non-smokers & non-drinkers
Head & neck and throat cancer has increased 225% from 1988 to 2004:
Smoking-related SCCA has decreased 50%
Of all HPV-driven SCCA, 60-64 year olds comprise 11.5%
Responds better to treatment than conventional SCCA
What type of HPV is most likely the cause of problems in the mouth?
HPV-16 most likely culprit in oral cavity
What is the management of oral SCC?
Wedge resection if on lower lip Clinical stage guides intraoral SCCA treatment --Wide excision --Radiation --Chemotherapy
What are the 5 year survival rates of those with oral SCC?
stage 1. 70%, 85%
stage 2. 50%, 75%
stage 3. 40%, 60%
stage 4. 25%, 50%
in oral cavity, and on lip
What are medical concerns with oral diseases?
Patients with complex medical history often require physician clearance prior to dental treatment
What conditions may affect dental treatment?
Cardiovascular disease --MI: no elective tx for 6 months after MI --Severe HTN: no tx until controlled --Take BP medication prior to dental tx Anticoagulant therapy --INR less than 3.0
What are additional conditions that may affect dental treatment?
Syncope
–Most common emergency in dental office
–May result from orthostatic hypotension or medications
Diabetes
–Should be well controlled
–Pts should eat & take insulin prior to dental tx
–Do NOT operate if blood glucose > 250 mg/dL
COPD
–May not tolerate supine position
What do we have to be cautious of in geriatric patients when giving them oral care?
Local injections
Lidocaine/xylocaine 2% with 1:100,000 epinephrine
Can cause cardiac abnormalities if injected intraarterially
Many older pts are sensitive to epi & may have palpitations
Toxicity
CNS symptoms, cardiac symptoms at high doses
Allergic reactions
Latex
Other dental materials
What are the antibiotic prophylaxis guidlines for dental work?
Necessary for 2 types of patients:
–Heart conditions with increased risk for infective endocarditis
Patients with a total joint replacement
–At risk for hematogenous infection
One hour before “any dental procedure that involves manipulation of the gingival or periapical region of teeth or perforation of the oral mucosa”
–If pt forgets, can take up to 2 hours after
What patients need antibiotic prophylaxis?
Heart conditions:
–Artificial valves
–Hx of infective endocarditis
–Cardiac transplant that develops a heart valve problem
Congenital heart conditions:
–Cyanotic congenital heart disease
–A congenital defect repaired with prosthetic material for 6 months after procedure
–Repaired congenital defect with residual defect
What patients do not need antibiotic prophylaxis?
Mitral valve prolapse Rheumatic heart disease Bicuspid valve disease Calcified aortic stenosis Congenital heart conditions: --Ventricular septal defect --Atrial septal defect --Hypertrophic cardiomyopathy
What is the usual agent used in antibiotic prophylaxis with oral care?
amoxicillin
