oral health problems in older people Flashcards
worry of current population trends
- Increasing proportion of population over age 65 years
- Increasing requirement for healthcare
- Difficulty accessing healthcare
- Reluctance to access healthcare
- Up to 75% have chronic disease
- Atypical presentation
- Polypharmacy
- Abnormal reactivity to drugs
- Compliance poor
categories of diseases that can affect the elderly
9
- predominately oral
- cardiovascular
- respiratory
- musculoskeletal
- haematological
- genito-urinary
- neurological
- psychological
- others
example oral medicine issues in elderly
- Lichen planus
- Mucous membrane pemphigoid
- Herpes zoster
- Post herpetic neuralgia
- Carcinoma
- Potentially malignant lesions
- Sore tongue
- Candidosis
example cardiovascular issues in elderly
- Hypertension and ischaemic heart disease
- Cardiac heart failure
- Temporal arteritis
example respiratory issues in elderly
- Chronic bronchitis and emphysema
- Pneumonia
example musculoskeletal issues in elderly
- Osteoarthritis
- Osteoporosis
- Paget’s disease
example haematological issues in elderly
- Anaemia
- Chronic leukaemia
- Multiple myeloma
example genito-urinary issues in elderly
- Urinary retention
- Urinary incontinence
- Prostatic hypertrophy and cancer
- Renal failure
example neurological issues in elderly
- Poor vision
- Multi-infarct dementia
- Parkinson’s disease
- Strokes
- Ataxia
- Trigeminal neuralgia
- Alzheimer’s disease
example psychological issues in elderly
- Insomnia
- Dependence on hypnotics
- Loneliness
- Depression
- Paranoia
- Acute confusional states
- Atypical facial pain
other medical issues that can impact elderly commonly
- nutritional deficiencies
- accidents
- malignancies
common issues elderly pts present with at dentist
7
- Denture related problems
- Dry mouth
- Drug reaction
- Trigeminal neuralgia
- Herpes zoster and post-herpetic neuralgia
- Burning mouth syndrome
- Oral cancer
what is this
Haemangioma
- Collection of tiny blood vessels
- Malformation
- Get venous lake
- Traumatised bleed
- Occur in any site of mouth. Commonly: inside of lip, edge of tongue, bunches sublingual
- Can grow large
- Removal – at hospital as risk of bleeding (specialist oral surgeon) cryotherapy
what is this
Fibroepithelial polyp FEP
- Can be smaller and larger
- Mucosa looks like its surrounding
- Caused by small trauma that hasn’t healed correctly so get build up of tissue (same tissue)
- Can be: Sessile (broad base) or on a stalk (easier to remove)
- Larger they get = harder to remove
Not a worry – but don’t let get too big
what is this
Black Hairy Tongue
- Less common now
- Extension/overgrowth of surface of tongue
- Pick up stains tannin (tea), red wine
- Unpleasant – aesthetics, smell
- Variation of normal – commoner in smokers
- Hard to get rid of as part of surface of tongue
- Clean from midline forwards (not back- down the throat)
- Soft toothbrush or tongue scraper
- Circular motions
what is this
Geographic Tongue/ Erythema migrans
- 10% population
- Variation of normal
- Can have degree of sensitivity (spicy, acidic)
- Atrophy surrounded by serpiginous margin (raised snake like margin)
- Can change over time
what is this
Atrophic Glossitis
- Smooth tongue (smooth and shiny instead of rough with coating)
- Uncomfortable
- Low iron/B12 level common cause
- Can lead to ulceration if iron level not amended
7 possible deture related problems
- traumatic keratosis
- frictional keratosis
- speckled leukoplakia
- sublingual keratosis
- denture-induced hyperplasia
- denture stomatitis
- angular cheilitis
traumatic keratosis
dentura related
fitting dentures but Move around
- See white patch where denture sits, when denture removed can see larger extent and tramlines of denture (cause of white patch)
- Ease denture in that area, relieve pressure in area -> review
- Rebase denture (if possible) or make new denture to avoid happening again
- Ease denture in that area, relieve pressure in area -> review
frictional keratosis
denture related
- white patch
- initial trauma with keratinisation around it
- deal with trauma and check white patch resolved
white patch found on mucosa and cannot ascribe a cause
biopsy
speckled leukoplakia
denture related
A.k.a hyperplastic candidiasis
Occurring in angle of mouth here
Unilateral or bilateral
More common in smokers (pipes)
Premalignant lesion -> follow up
- Initially microbiological swab – idea of how much candida is there
- Then biopsy -> oral medicine
sublingual keratosis
denture related
Important to check under a tongue
- Lateral tongue, ventral tongue and buccal corridoes are the most common place for pathologies to be
White pathches crosses midline (worse on pt left)
Refer to oral medicine
denture induced hyperplasia
Common in elderly
Due to Lower denture doesn’t fit (more likely than upper)
- Flaps of tissue made as mouth tries to protect itself
- ridge, ridge and another ridge and ulcerated
- Uncomfortable
Remove denture to see if can get some that to tissue to disappear (longer been there less likely)
- If pt healthy enough can surgically remove some or cut the denture back dramatically allowing area to be eased so no pressure on
- Flaps look exactly like other mucosa in mouth - just trying to protect itself*
issue here
denture stomatitis
likely the denture was stabilised with mucosa – hard to deal with
denture stomatitis
Common
Often people unaware they have it as generally painless
Need to remove denture on examination
- See area of erythema corresponds exactly to where the denture fits
- Due to candida infection (e.g. candida albicans, can be multiple)
- Hyphae burrow into surface of mucosa and plastic of denture
- Due to candida infection (e.g. candida albicans, can be multiple)
Do they wear denture continuously? Denture hygiene?
- Soak in dilute solution of sodium hypochlorite 20-30mins, rinse and leave in water for another 30mins – bare minimum
angular cheilitis
Candida, bacterial or mixed
Cracks and masserations at corner of mouth
Hard to heal
Common reservoir of infection intra-oral (denture)
- Staphylococcal element common
Deal with problem before medicating – check if problem Making drool? Take bloods – iron levels?
Skin folds in elderly – moist painful area as face not cleaned and dried properly – uncomfortable
how to test for xerostomia
Use mirror, place on tongue -> sticks
indication saliva not of right quality
potential causes of xerostomia
- Sjogren’s syndrome,*
- polypharmacy (culmulative effect),*
- drug side effect (right)*
- radiotherapy of head and neck (left)*
management of xerostomia
- Change medication
- Primary cause – often hard to change
- Salivary replacement – shortlived effects
- Salivary stimulants
- Chewing gum
- Beware strain on TMJ
- Glycerine and lemon
- Acidic Historically popular
- Chewing gum
salivary replacement options
Saliva Orthana
- pH neutal
- has F
GlandosanepH 5 ish
- Acidic - no
Biotene Oral Balance
BioXtra
issue here
xerostomia
- Floor of mouth should be delicate – thin mucosa see BV through it*
- But here quite meaty floor of mouth with horizontal keratotic lines (heavy smoker) – protective
- Dry – medication*
- Abrasion by 35 as stuck and torn when speaking – portal of entry for microbes (plentiful as there is reduced clearance*
possible topical drug reactions in oral cavity
aspirin and iron tablets mainly
other drugs can cause lichenoid reactions
aspirin tablet effect on oral cavity
- often put next to tooth to try and help pain but actually just burns mucosa
take with water
iron tablets effect on oral cavity
if they are left in contact with mucosa for length of time will burn mucosa
- difficult to swallow -> liquid iron (messy but not dangerous)
lichen planus
mucosubcutaneous disorder affecting 1-2% of UK population
dermatological condition
- 2 types lichen
- Skin
- Oral can be all the way through digestive tract - pain
- If you have oral lesions – may not have skin lesions*
- If you have skin lesions – likely to have oral lesions*
Characterised by white striae
oral lichen planus sites
characterised by white striae
Mainly effective: buccal mucosa, lips, tongue, attached gingiva
Rare on palate – more likely to be lichenoid reaction than true lichen planus
lichenoid reactions
more common than lichen planus
mimic lichen planus but not a result of autoimmune condition, they are a direct reaction to drugs
drugs which can cause lichenoid reactions
- NSAIDs
- β-blockers
- Diuretics
- Oral hypoglycaemics
- Statins
- Antialarials
- Sulphonamides
Many drugs cause lichenoid reaction
skin lichen planus appearance
skin get purple, polygonal almost patches with white lines across
itchy
oral lichen planus/lichenoid reactions
charcterised by white striae
many subtypes, can have more than one
- reticular (left) – roughness to cheek but generally asymptomatic
- erosive – painful
- plaque,
- atrophic
cannot be managed in high street – need oral medicine
bisphosphonates
Inhibit osteoclast formation, migration and osteolytic activity
- Incorporated in skeleton
- Inhibit bone turnover
- No repair of microdamage
- Tooth extraction – break cancellous bone supporting the tooth, not repaired
- No repair of microdamage
- Anti-angiogenic
uses of bisphosphonates
- Non-malignant
- Osteoporosis
- Paget’s disease
- Osteogenesis imperfecta
- Fibrous dysplasia
- Primary hyperparathyroidism
- Osteopenia
- Malignant
- Multiple myeloma
- Breast cancer
- Prostate cancer
- Bony metastatic lesions
- Hypercalcemia of malignancy
bisphosphates and extractions
they are very common good drugs that pts need to be on
however complications in extractions
- Inhibit bone turnover
- No repair of microdamage
- Tooth extraction – break cancellous bone supporting the tooth, not repaired
- No repair of microdamage
how to manage patients on bisphosphonates
SDCEP Guidance
induced osteonecrosis
MRONJ
risk factors for MRONJ
- Extremes of age
- Concurrent use of corticosteroids
- Systemic conditions affecting bone turnover
- Osteopenia, osteoporosis
- Malignancy
- Myeloma, breast cancer etc
- Coagulopathies, chemotherapy, radiotherapy
- Duration of therapy
- Reduced recently – 3 years max
- Previous diagnosis of BRONJ
- Potency of drug
- As well as delivery – IV greater risk over oral
- Invasive dental procedures
- Surgery – extraction, flap
- Denture trauma
- Fine mucosa and denture rubs on bone
- Consider soft base on denture
- Fine mucosa and denture rubs on bone
- Poor oral hygiene
- Periodontal disease
- Alcohol or tobacco use
- Thin mucosal coverage – link to denture
issue here
Old lady with myeloma
- Broke wisdom tooth
MxH and drugs not disclosed
- Went back multiple times as bone coming out ???
- But she had medical related osteonecrosis of jaw
More common in mandible
Get sequestrian of bone
- Bone dies away and gum doesn’t heal – get open area in mouth – needs clean at all time
pt advice if dental extraction needed and on bisphosphonates
- Advise patient of BRONJ risk
- Informed consent
- Emphasise rarity of condition e.g. oral palindromic acid (IV hgher)
- Don’t discourage from taking medication
CHECK SDCEP
general pt advice for all
- Regular dental checks
- Maintain good oral hygiene
- Limit alcohol and stop smoking
- Report any symptoms (e.g. loose teeth, pain, swelling)
what is this
Herpes Zoster (shingles)
- Any branch of CNV*
- Prodroma pain then unilateral rash*
- Often ask for tooth extracted as pain but tooth is healthy
- Painful*
post herpetic neuralgia
not that common in practice
- Previous episode of shingles
- Constant burning sensation in dermatomal distribution
- Any part body, face
- Resolves within 2 months in 50%
- May persist for two years or longer
-
Suicide risk – unremitting pain
- Psychological effect
-
Suicide risk – unremitting pain
- May persist for two years or longer
- Incidence possibly reduced by antiviral therapy ± steroids
treatment of post herpetic neuralgia
- Antidepressants
- Gabapentin
- Carbamazepine
- Topical capsaicin 0.025%
- Transcutaneous electrical nerve stimulation (TENS)
trigeminal neuralgia
occurance
- any of the 3 branches
- Mandibular most
- More women> men
- “10/10” “electric shock pain” excruciating
- Not constant
- Just comes on
medications for trigeminal neuralgia
- Carbamazepine
- Only drug licenced for this currently - on dental list
- Base line bloods, liver function
- Low and build until pain free
- Base line bloods, liver function
- Only drug licenced for this currently - on dental list
- Oxcarbazepine
- Gabapentin
- Pregabalin
- Lamotrigine
- Sodium valproate
- Phenytoin
serious issue with trigeminal neuralgia
- request surgical opinion*
- Presents with new trigeminal neuralgia – request MRI – look for impingement of nerve*
surgical management of trigeminal neuralgia
- Peripheral Procedures
- Cryotherapy
- Injection of alcohol or glycerol
- Neurectomy
- Avulsion of nerve
- Ganglion procedures
- Balloon compression
- Radiofrequency thermocoagulation
- Alcohol or glycerol injection
- Microvascular decompression
- Gamma knife radiosurgery only 1 site in England
is surgical management of trigeminal neuralgia effective for elderly
yes
less likely to have to constantly take pills
2 conditions to consider in trigeminal neuralgia pt
-
esp if younger
- Multiple sclerosis
- Space occupying lesion
MRI scan
burning mouth syndrome occurance
- More common in females (F:M = 3:1)
- +/- anxiety, stress
- +/- depression
cause of burning mouth syndrome
No cause identified in 50% patients
- Psychogenic in 20%
- Drugs (ACE or protease inhibitors)
- Dry mouth
- Candidosis
- Haematinic deficiencies – FBC, folate, ferritin, B12, blood sugar
- Diabetes
- Parafunctional activity – clenching, grinding
- Denture factors
- Hypothyroidism
- Allergy
Reassure not cancer
sequalae of burning mouth syndrome
- May lead to malnutrition
- Don’t want to eat
- Slow rehabilitation
- Slow recovery
- Reduce quality of life
need conservative management (tricyclic, antistress, mindfulness)
Any ‘burning mouth remedies’ don’t help
- just make worse if anything,
chemicals irritate mucosa
oral cancer screen
should be detected in oral mucosal screen an regular appointments
- anything abnormal -> refer
- Better to be safe then sit and wait and monitor
- Never examine mouth with denture in place and move tongue to see all areas of mucosa*
- Carcinoma can be tucked into denture
exam in systematic way
- less likely to miss something
what are these
oral cancers
advanced
treatment not pleasant
what are these
oral cancers
- Speckled lesion, slightly exophytic buccal mucosa (carcinoma)*
- Can be missed – hurry, poor light – TAKE TIME
this is
- A large exophytic lesion with an ulcerated base and heaped up margins.*
- Neglected mouth – a not atypical presentation*
importance of removing dentures for examination
oral cancer carcinomas can be tucked into denture
