Oral Conditions Book Chapter by Dr. Jude Fabiano

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Oral Conditions Jude A. Fabiano

CLINICAL PEARLS 473

DEMENTIA 488

EVALUATION OF THE ORAL CAVITY 474

CONCLUSION 488

DENTAL DECAY (CARIES) 476

CLINICAL PEARLS

PERIODONTAL DISEASE 478 ■

DIET AND NUTRITION 480 ■

XEROSTOMIA 480 ■

OROFACIAL PAIN 481

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ORAL MEDICINE AND THE ELDERLY 482

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ORAL CANCER 482

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ORAL MUCOSITIS 484

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ORAL CANDIDIASIS 484 TRAUMATIC LESIONS 485 BURNING MOUTH SYNDROME (STOMATOPYROSIS) 486 ORAL CONDITIONS AND SYSTEMIC DISEASE 486 PERIOPERATIVE CONSIDERATIONS 486 ATHEROSCLEROSIS, CARDIOVASCULAR DISEASE, AND STROKE 487 DIABETES 487 ASPIRATION PNEUMONIA/CHRONIC OBSTRUCTIVE PULMONARY DISEASE 487

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Oral health is intimately associated with general health and well-being.

Poor oral health negatively affects nutrition and systemic health.

Dental caries and periodontal disease are preventable.

Xerostomia can have devastating effects on the health of the hard and soft tissues of the oral cavity.

Root surface dental decay, often a secondary effect of xerostomia, has an increased incidence in older adults.

Medications with xerostomic side effects should be avoided when possible.

Diagnosis of orofacial conditions in elderly persons may be confounded by coincident medical and dental conditions, multiple medications, and vague histories.

The 5-year survival rate of oral cancer has not improved over the past 30 years. Early diagnosis is crucial.

Proper oral hygiene in older adults prevents several life-threatening systemic conditions.

Follow current recommendations regarding antibiotic prophylaxis and anticoagulant therapy as they relate to dental procedures.

Good oral health has emerged as a critical factor in maintaining general health in geriatric individuals. The oral cavity provides an entrance to the body for every nutrient necessary for life except oxygen. Over the past several decades, the number of older adults who have retained some or all of their natural teeth has dramatically increased.

While this has resulted in improved masticatory function and self-image, the risk for acute and chronic oral disease persists later in life. Periodontal disease, dental caries, root surface caries, infections, oral cancer, malocclusion, missing

AQ1 AQ2

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teeth, and weakness of the orofacial musculature can all inhibit the intake of nutrients and impact the general health of an individual. Compromised oral health has been linked to cardiovascular and cerebrovascular disease, pneumonia, and diabetes. In addition, feelings of social well-being and self-image, quality of life, life satisfaction, and psychological well-being are directly related to an individual’s oral health.

Oral health problems are among the most common chronic conditions found in older people. While only 35% of patients 75 years and older visit a dentist annually, almost 90% of this group see physicians. It is critical, therefore, that physicians be familiar with oral pathology, perform thorough intraoral examinations on their elderly patients and be prepared to manage and/or refer patients for definitive treatment.

This chapter provides basic knowledge of the oral conditions that affect the systemic health and quality of life of older people, and of oral findings related to systemic conditions found in these individuals.

Figure 35.2 Bidigital palpation on lower lip. (See color insert.)

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Key to identifying and assessing oral conditions is the ability to perform a comprehensive hard and soft tissue oral examination. A complete head and neck examination should precede the intraoral examination, including physical inspection of the head, facial form, skin, eyes, ears, nose, temporomandibular joint, neck, thyroid gland, and cranial nerves. Intraoral physical examination should then proceed as follows:

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Figure 35.1 Normal appearance of lips. (See color insert.)

Buccal Vestibule. Located at the junction of buccal mucosae and alveolar process. Examine for elevations or depressions. Palpate at height/depth of vestibule to identify tenderness or swelling (see Figs. 35.4 and 35.5).

Common Abnormalities: Inflammatory lesions associated with dental abscesses.

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Lips. Pale pink, homogeneous in color, well-defined border with skin. Bidigital palpation performed to identify uniform submucosal consistency and thickness (see Figs. 35.1 and 35.2).

Common Abnormalities: Ulcerations, irregular surface, white thickenings, recurrent herpetic lesions.

Buccal Mucosae. Uniformly pink/red in color; visualize Stensen duct and check for normal salivary flow. Bidigital palpation to rule out submucosal thickenings or tumors (see Fig. 35.3).

Common Abnormalities: Biteline hyperkeratosis, fibromas, candidiasis.

EVALUATION OF THE ORAL CAVITY

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Hard Palate. Utilize direct visual inspection. Uniform pink color. Evaluate rugae, palatal raphe, palatine papilla, and maxillary tuberosities (see Fig. 35.6).

Common Abnormalities: Maxillary torus, candidiasis, papillary hyperplasia.

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Soft Palate:. Utilize direct vision/mouth mirror; depress tongue if necessary. ‘‘Ah’’ for elevation, which should be

Figure 35.3 Bidigital palpation of buccal mucosa. (See color insert.)

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Figure 35.4 Visual examination of anterior buccal vestibule, mandibular arch. (See color insert.)

bilaterally uniform. Evaluate uvula for size, color, and texture (see Fig. 35.7).

Common Abnormalities: Candidiasis, swelling, ulcerations, nicotine stomatitis.

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Oropharynx. Depress tongue and have patient say ‘‘ah.’’

Evaluate tonsils (usually atrophic in elders) and posterior wall of pharynx (see Fig. 35.8).

Figure 35.6 Visual examination of hard palate. (See color insert.)

Common Abnormalities: Erythema, exudate, asymmetry.

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Tongue. Have patient extrude tongue and wrap tip with gauze to properly visualize lateral borders. Assess ventral, lateral, and dorsal surfaces, including papillae, lingual frenum, and vasculature (see Figs. 35.9 and 35.10).

Common Abnormalities: Ulcerations, fibromas, ‘‘brown/ black hairy tongue’’ (especially in smokers), geographic tongue. Posterior one third of lateral border is most frequent site of oral cancer.

Figure 35.5 Visual examination of posterior buccal vestibule, mandibular arch. (See color insert.)

Figure 35.7 Visual examination of soft palate. (See color insert.)

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Figure 35.8 Visual examination of oropharynx. (See color

Floor of Mouth. Visualize as tongue is elevated. Uniform red color. Evaluate Wharton ducts for salivary flow. Bidigital palpation to evaluate submandibular salivary glands, lymph nodes, symmetry (see Fig. 35.11).

Common Abnormalities: Ulcerations, varicosities, mucocele.

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Gingivae. Observe color (pink), frenal attachments, and recession.

Common Abnormalities: Inflammation secondary to periodontal disease, recession, hyperplasia, fistulae (see Fig. 35.12).

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Teeth. Number present/absent, gross decay, plaque/calculus, mobility, discoloration, and occlusion (Fig. 35.12).

Common Abnormalities: Decay, mobility, gingival abrasion, fractures, lost/fractured restorations, ill-fitting prosthesis.

Figure 35.9 Visual examination of dorsal surface of tongue. (See color insert.)

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insert.)

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Figure 35.10 Visual examination of lateral surface of tongue, including lingual tonsil. (See color insert.)

DENTAL DECAY (CARIES) CASE ONE Mr. K., a 68-year-old in good general health and taking no medications, has been visiting his dentist every 6 months for an oral examination and prophylaxis (cleaning). Mr. K. historically had a very low caries rate and had not been diagnosed with a carious lesion in over 15 years. Four months prior to his most recent dental visit, Mr. K. was placed on nifedipine for the management of mild hypertension. Shortly after the initiation of the drug, Mr. K. experienced a feeling of dryness in his mouth that affected his ability to properly chew food, swallow, and speak. To counteract these difficulties, he began to suck on lemon drops and to drink soda frequently during the day and during the night as well. Four months after the initiation of the nifedipine therapy, dental examination revealed multiple root surface carious lesions, some moderate in size. Mr. K.’s physician was consulted, an alternative antihypertensive agent without xerostomic side effects was identified and the nifedipine was replaced. The carious lesions were restored and the

Figure 35.11 Visual examination of floor of the mouth, including Wharton ducts. (See color insert.)

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Figure 35.12 Visual examination of anterior gingival and teeth.

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Figure 35.13 Root surface caries. (See color insert.)

(See color insert.)

patient was placed on daily topical fluoride treatments and instructed to use sugarless lemon drops and frequent sips of water, not sugar-containing beverages, to reduce the feeling of dry mouth. Mr. K. was subsequently placed on a 3-month examination interval. No additional carious lesions have formed and Mr. K. no longer has the feeling of dryness in his oral cavity.

Dental caries is the demineralization of the calcified structures of the tooth caused by Streptococcus species and other intraoral bacteria. Caries may occur on the smooth, pit and fissure and root surfaces of the tooth. Smooth and pit and fissure caries occur on the enamel surface and have a higher incidence in children and young adults. Root surface caries typically affect older adults and develop on the dentin surface of the root in areas where gingival recession has occurred. As an increased number of older people maintain their natural teeth, they are predisposed to root surface caries. Other local factors, such as xerostomia, increased sugar intake, acidic foods and drinks, and medications, increase the likelihood that root surface caries will develop.

Dental decay is preventable, with the removal of bacteria-harboring dental plaque. Dental caries occur when three components are present: ■ ■ ■

A tooth surface (enamel and/or dentin) A fermentable substrate (i.e., sugar) Bacteria that metabolize fermentable substrates into acids.

The acids produce a result in the demineralization of the tooth surface and cavitation. Removal of one of the three components will interrupt the decay process and prevent caries from developing. Pit and fissure and smooth surface caries occur on enamel, the hardest substance in the body, and may take months to develop. However, root surfaces are not covered with enamel. Their surface has a thin layer of cementum, which quickly dissolves and exposes dentin.

Dentin has a less mineralized composition than enamel, and the decay process on this surface will develop much more rapidly.

Root surface caries is a particularly difficult management issue in the older adult (see Fig. 35.13). Approximately half of all adults 75 years and older have at least one tooth with root surface decay. Individuals who have been caries-free for decades may develop a number of root surface carious lesions in a matter of weeks. Usually this type of episode follows a major change in the oral environment. Medications that cause dry mouth as a side effect are often a contributor. This, coupled with the attempts to counter the dry mouth by frequent use of high-sugar, acidic drinks, and/or candy lozenges, results in the rapid demineralization of the dentin on the root surface and may result in irreparable cavitation and the subsequent loss of the tooth. Care should be taken to avoid medications with a xerostomic effect, and to advise patients to see a dentist for frequent, regular evaluations when their use is unavoidable. Other factors contributing to caries in older adults include history of previous caries, number of existing dental restorations, dietary habits, lack of fluoride exposure, and presence of partial dentures, which often cause food retention and subsequent plaque formation, diminished oral and/or manual motor control, being dependent on others for oral hygiene, systemic disease(s), and infrequent dental visits.

Unless properly treated, dental caries can lead to abscess formation of the hard and soft tissues of the oral cavity, cellulitis (including Ludwig angina), infection of proximal structures (cavernous sinus thrombosis), septicemia, and systemic seeding (subacute bacterial endocarditis). Extraction of the infected tooth may be necessary, affecting dental occlusion, mastication, and nutritional intake.

Prevention of dental caries is focused on: ■ ■ ■ ■ ■ ■

the mechanical removal of dental plaque through proper brushing and flossing; the reinforcement of the composition of enamel through fluoride treatments; diet modification; the use of antimicrobial rinses; early attention to salivary dysfunction; and professional prophylaxis and intervention at appropriate intervals.

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Management of dental caries is through removal of the carious lesion and repair of the tooth with the appropriate dental material. Management of dental infections is primarily mechanical, either through root canal therapy, incision, and drainage or extraction. Use of antibiotics should be reserved for the treatment of established abscess formation, and inappropriate prescription of antibiotics should be avoided. Referral to the appropriate dental professional should be the first course of action.

Table 35.1 highlights medications that are useful in the management of oral conditions often found in elderly people.

PERIODONTAL DISEASE CASE TWO Ms. H. is an 84-year-old with a medical history significant for Parkinson disease. She has been a resident in a long-term care facility for 8 years and is currently confined to bed for most of the day. She has severe tremor of her extremities and head and neck, making oral hygiene difficult at best. The gross amounts of bacteria-harboring dental plaque and calculus that have formed on her teeth and gingival tissues have contributed to the development of a severe case of periodontitis. Ms. H. has dysphagia associated with Parkinson disease and frequently aspirates particles of food during swallowing. Following a

case of pneumonia due to cultivable oral flora in her sputum, Ms. H. was placed on a vigorous daily regimen of oral hygiene and frequent oral prophylaxis to reduce the development of dental plaque and calculus, which directly reduced the severity of her periodontitis and her risk of subsequent aspiration pneumonia events.

Periodontal disease (gingivitis and periodontitis) is a host-mediated response to bacteria found in dental plaque resulting in the destruction of the supporting structures of the teeth, namely the gingiva and associated soft tissues, periodontal ligament, and alveolar bone. It is a chronic, progressive condition affecting >80% of people older than 65 and is the most common reason for tooth loss in individuals older than 40. Evidence exists indicating that periodontal disease can increase the risk for cardiovascular disease and respiratory diseases, and accelerate the progression of diabetes (see section ‘‘Oral Conditions and Systemic Disease’’).

Signs and symptoms of periodontal disease include erythema and inflammation of the gingival tissue, bleeding of the gingival tissue during brushing, and tooth mobility (see Fig. 35.14). Gingival recession is found in most older adults, although it is not always due to a disease process (‘‘long in the tooth’’). It is significant because it exposes root surfaces, which leave the tooth susceptible to root surface caries (see section ‘‘Dental Decay’’). In advanced stages

TABLE 35.1 MEDICAL MANAGEMENT OF ORAL CONDITIONS Indication

Medication/Directions

Caries prevention

■ 0.2% neutral NaF rinse

Strength of Evidence of Effectiveness A

Disp: 480 mL bottle Sig: Rinse 10 mL for 1 min and expectorate; do not swallow Repeat weekly ■ 1.1% neutral NaF dental cream (PreviDent 5,000)

A

Disp: 2 oz tube Sig: Place 1/2 inch ribbon on toothbrush, then brush for 2–3 min and expectorate; do not swallow; do not rinse or eat for 30 min following treatment Perform twice daily Periodontal disease

■ Chlorhexidine gluconate 0.12% (Peridex, PerioGard)

A

Disp: 16 oz bottle Sig: After brushing and flossing teeth, rinse 1/2 oz for 30 s twice daily and expectorate Xerostomia

Saliva substitutes ■ Sodium carboxymethylcellulose 0.5% aqueous solution (Saliva Substitute, Salivart) Disp: 8 fl oz Sig: Rinse as frequently as needed

C

Salivary stimulants

B

■ Pilocarpine HCl (Salagen) tablets 5 mg

Disp: 21 tablets Sig: Take 1–2 tablet(s) 1/2 h prior to meals

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TABLE 35.1 (continued ) Oral mucositis AQ3

Topical analgesic rinses ■ Diphenhydramine (Benadryl) elixir 12.5 mg/5 mL and attapulgite (Kaopectate) Disp: Mix equal parts of both liquids (4 oz each) to obtain 8 oz Sig: Rinse one teaspoon every 2 h for 1 min and expectorate

C C

■ Aminacrine (Kamillosan liquid) 30 mL

C

Disp: Mix 30 drops in 100 mL of warm water Sig: Rinse 5–10 mL four times daily for 1 min and expectorate ■ Dyclonine HCl (Dyclone) 0.5% or 1%

B AQ4

Disp: 1 oz bottle Sig: Rinse one teaspoon for 2 min and expectorate Intravenous therapy ■ Palifermin (60 µg/kg/d) intravenously for 3 d immediately before starting high-dose

chemotherapy and total-body irradiation (conditioning therapy) and then again for 3 d after stem-cell transplantation.

Oral candidiasis

Candidiasis ■ Nystatin (Mycostatin, Nilstat) oral suspension 100,000 U/mL

A

Disp: 240 mL Sig: Rinse 5 mL four times daily for 2 min and swallow until finished ■ Nystatin lozenge (Mycostatin pastilles) 200,000 U

Disp: 70 pastilles Sig: Dissolve one pastille in mouth five times daily for 14 d; do not chew or swallow whole ■ Clotrimazole (Mycelex) troches 10 mg Disp: 70 troches Sig: Dissolve one troche in mouth five times daily for 14 d; do not chew or swallow whole Angular cheilitis

A A AQ5 AQ6

A

A

■ Nystatin-triamcinolone acetonide (Mycolog II, Mytrex) ointment

Disp: 15 mg tube Sig: Apply to affected areas four times daily for 10–14 d ■ Clotrimazole-betamethasone dipropionate (Lotrisone) cream

Disp: 15 mg tube Sig: Apply to affected areas four times daily for 10–14 d NaF, sodium fluoride.

of periodontal disease, pain, swelling, and acute abscess formation may occur.

Management is based on prevention, and early recognition of periodontal disease is by far the best management approach. Removal of dental plaque through proper oral hygiene practices is key and includes: ■

■ ■ ■

Figure 35.14 Severe periodontal disease. (See color insert.)

brushing with a soft, polished tipped bristle toothbrush, including those that are battery-operated or have modified handles, at least twice per day; flossing between all teeth every day; proper use of antimicrobial rinses, such as chlorhexidine; and frequent professional oral prophylaxis and/or periodontal therapy.

Recent developments in surgical and bone-grafting procedures have increased the success of periodontal treatments.

Gingival hyperplasia may develop in older individuals associated with the use of phenytoin, cyclosporine, and calcium channel blockers. Selection of an appropriate alternative

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medication in most cases will reverse the condition. However, in selective cases surgical removal of the hyperplastic tissue may be necessary.

DIET AND NUTRITION

lubrication for swallowing. Conditions that negatively affect the orofacial musculature, particularly the muscles of mastication, certainly contribute to older people’s limited food choices. Attention must therefore be given to all of the multiple components of the masticatory system and to optimizing the effects of each component to maximize a varied food intake, chewing efficiency, and nutritional status.

CASE THREE Mr. J., a 78-year-old with a medical history significant for well-controlled insulin-dependent diabetes, was diagnosed with severe periodontal disease that necessitated removal of all of his remaining maxillary (upper) natural teeth. Immediately following the dental extractions, a maxillary interim (temporary) denture was placed to restore minimal masticatory function, postoperative instructions were given, and the patient was dismissed in satisfactory condition. Mr. J. returned the following day for reevaluation. On his way to the dental operatory he became light-headed, lost his balance and collapsed into the arms of the dental auxiliary. He was placed in a supine position and upon questioning stated that while he administered his normal dose of insulin this morning, he had not eaten due to the ‘‘strange feeling of the denture’’ in his mouth.

Glucometer testing indicated a blood glucose of 48 mg per dL. Following a sugar-containing beverage, a blood glucose level of 136 mg per dL was recorded. Proper insulin administration and food ingestion instructions were again reviewed and he was discharged in satisfactory condition in the company of a responsible adult. He reported no subsequent events on follow-up appointments.

AQ7

Satisfactory oral health in older people also involves masticatory ability that allows consumption of foods of all types and consistencies. Impaired chewing ability often restricts food choices to predominately soft, easy-to-chew items, therefore limiting many foods essential for proper nutrition. Adequate mastication is not only dependent on the absence of caries and periodontal disease, but on the number of remaining natural teeth, the number of occlusal (grinding) contacts existing regarding posterior teeth, the amount and type of saliva, and the proper function of the orofacial musculature. Inability to properly chew food and xerostomia also alter taste perception and may further limit food selection.

Compromised masticatory ability places the patient at risk of consuming below-optimum amounts of specific nutritional components, including vitamins A, B6 , and C, folic acid, carotene, calcium, niacin, and dietary fiber.

Absent healthy teeth, they consume less protein and more carbohydrates. Maintenance and restoration of natural teeth and/or clinically acceptable prosthetic replacement of missing posterior teeth are associated with a more varied food item selection and a better nutritional intake.

The ability to masticate properly is also dependent on the quality and quantity of saliva to allow proper bolus formation, initiate the digestive process, and provide adequate

XEROSTOMIA CASE FOUR Ms. N., a 74-year-old with a medical history significant for Parkinson disease, presented with the chief complaint of a ‘‘loose upper denture.’’ Clinical examination revealed a well-fitting maxillary complete denture with inadequate retention secondary to the lack of sufficient saliva to create a proper denture/tissue seal. Ms. K. stated that the denture, which had been fabricated 4 years ago, ‘‘fit fine’’ until she noticed a dryness in her mouth approximately 6 months ago. Further questioning revealed the addition to her anti-parkinsonism medications of trihexyphenidyl (Artane) at approximately the same time the denture retention issue developed. She was unable to eat her normal diet and lost 16 pounds over that same period.

Following consultation with Ms. K.’s physician the trihexyphenidyl was discontinued, which did not have a negative effect on her symptoms and resulted in increased salivary flow, improved denture retention and the return of her normal eating habits.

Saliva is formed by the major salivary glands and numerous minor salivary glands, with most saliva produced by the major salivary glands. Two types of saliva are produced: Mucous and serous. Saliva acts to lubricate the oral cavity, increases the pH of the oral cavity, which protects against caries formation and promotes remineralization of tooth surfaces, aids in digestion and taste sensation, maintains mucosal integrity, is critical for proper denture stability and retention and functions as an antimicrobial agent.

Xerostomia is the subjective feeling on the part of an individual of decreased saliva and a dry mouth. It is a common complaint in older people; however, it is not always associated with objective findings of diminished salivary flow. The aging process itself is not the cause of xerostomia. Mouth breathing, obstruction of major salivary ducts, side effects of medications, metabolic changes, and many local and systemic disease processes and/or treatments contribute to this condition. Over 500 medications have been identified as causing xerostomia, and most drug-induced xerostomia is reversible. Patients often experience a decreased salivary flow with neoplasms of the head and neck and with surgical intervention and/or radiotherapy of these tumors. Radiation therapy may affect both the quality and quantity of saliva produced, often resulting in thick, mucous saliva. Xerostomia has been associated with increased and often rampant caries

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formation, compromised chewing and swallowing ability, inability to wear dentures, breakdown of mucosal tissues, and microbial overgrowth, including Candida sp of the oral cavity and bacterial sialadenitis.

Treatments for xerostomia are based on removing the cause or on replacement therapies. Alternate medications should be substituted whenever possible for agents that cause xerostomia. Drug families identified as causing xerostomia include anticholinergics, antihistamines, antihypertensives, anti-parkinsonians, antidepressants, bronchodilators, diuretics, and sedatives. Proper shielding and tissue preservation techniques should be utilized in patients receiving radiotherapy for tumors of the head and neck. Early diagnosis and treatment of conditions causing xerostomia, such as Sjögren syndrome, are essential in maintaining salivary function.

While the ideal salivary substitute has yet to be developed, several methods are recommended to aid in the lubrication of the oral cavity and reduce discomfort in those patients with xerostomia: ■ ■ ■ ■ ■ ■ ■ ■ ■

■

■ ■ ■

Frequent sips of cool water and/or allowing ice chips to melt in the mouth Drinking milk, which has lubricating and moisturizing properties, with meals Use of a cool mist air humidifier, especially while sleeping Decreased use of alcoholic drinks and alcohol-containing mouthwashes Decreased intake of caffeine Use of sugar-free gum (Xylitol), candies (Koolerz, Smint Mints), and beverages to stimulate salivary flow Application of a lubricant (Vaseline) on lips Sleeping on one’s side to avoid/reduce mouth breathing Use of saliva substitutes • Liquids (Saliva Substitute, Salivart, Xero-Lube) • Tablets (Salix) • Sprays (Optimoist) • Gels (Oralbalance) • Toothpaste (Biotene toothpaste).

Use of cholinergic agonists, when appropriate • Pilocarpine, 5 to 7.5 mg t.i.d.

• Cevimeline, 30 mg t.i.d.

Immaculate oral and prosthesis hygiene Daily application of fluoride to teeth Frequent, regular professional oral evaluation and prophylaxis.

OROFACIAL PAIN

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swelling of and tenderness to palpation associated with the right temporal artery. Additional questioning of the patient revealed recent visual disturbances of the right eye. A preliminary diagnosis of giant cell (temporal) arteritis was substantiated by an elevated erythrocyte sedimentation rate of 140 mm per hour. The patient was immediately placed on prednisone 60 mg per day to reverse the ophthalmic effects and prevent permanent loss of vision.

While giant cell arteritis and polymyalgia rheumatica may occur separately, they often occur in the same individual, especially in those older than 60. Jaw claudication secondary to diminished blood flow to the muscles of mastication, which results in pain during chewing, swallowing, and/or talking, is a common complaint and may be the presenting symptom.

Older people often develop pathologic conditions of the head and neck that produce painful symptoms of differing character, duration, and intensity. Determining the etiology of orofacial pain is hampered by other coincident medical and dental conditions, multiple medications, and vague histories. It is important to remember that symptoms, including pain, from systemic conditions may radiate to the head and neck and mimic pain with an odontogenic cause. Assessment of pain in older adults may be facilitated by the use of the Visual Analog Scale and FACES Scale (e.g., see ‘‘Wong-Baker FACES Pain Rating Scale’’ citation in the Selected Reading), both of which have high reliability and validity, and by thorough cranial and autonomic nerve examinations. They are easy to use and aid in the assessment of pain and evaluation of the effectiveness of treatment.

The source of pain in older people can be from conditions that have an inflammatory/infectious, neoplastic, traumatic, developmental, and/or psychological origin. It is not uncommon for the painful area to be distant from the location of the cause of the pain. An intracranial tumor exerting pressure on a cranial nerve may result in pain being felt on the distal distribution of the nerve. If the tumor causing the pain is metastatic, the primary lesion may be quite distant indeed.

Diagnosis should be approached in a systematic manner.

Locating the distribution of pain may point to a specific dermatome(s), unilateral/bilateral nature, and recruitment of additional pain pathways. Determination of the origin of the tissue involved as well as examining the character and duration of the pain will narrow the differential diagnosis.

Pain-producing conditions that characteristically occur in older individuals:

CASE FIVE

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Mr. F., an 80-year-old with a medical history significant for rheumatoid arthritis, presented to his dentist with the chief complaint of difficulty in chewing and pain on the right side of his head. Clinical examination revealed

■

Arthritis of the cervical vertebrae may limit mobility of the head and neck and produce pain. Diagnosis should be confirmed by imaging techniques to rule out other causes. Physical therapy and analgesics are of benefit.

Carotidynia, tenderness of the carotid bulb, may cause neck pain related to head movement. Treatment with

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nonsteroidal anti-inflammatory drugs is recommended and usually effective.

Eagle syndrome, the mineralization of the stylohyoid ligament that essentially elongates the styloid process, may produce short bursts of sharp pain when the head is turned from side to side and/or on swallowing. Surgical resection of the mineralized ligament will eliminate the painful symptoms.

Table 35.2 outlines the varying sources, characteristics, and duration of orofacial pain found in older adults.

ORAL MEDICINE AND THE ELDERLY Oral medicine, the study of oral disease caused by local or systemic conditions, has become an important branch of medicine and dentistry, particularly in older adults. These individuals present with a greater frequency of medically compromising conditions, many with oral findings, oral mucocutaneous disease, and/or orofacial pain. The net result is often compromised nutrition, communication disorders, poor self-image, and reduced quality of life.

Oral conditions, such as periodontal disease, may play a role in the development of life-threatening conditions, such as cardiovascular disease and aspiration pneumonia.

The health of oral tissues, therefore, is critical to the overall health of older people.

ORAL CANCER CASE SIX Mr. M., a 62-year-old with a 45-year history of heavy cigarette smoking, presented for a periodic oral examination and oral prophylaxis. Intraoral examination revealed a 4 Ă— 5 mm white papule on the left lateral posterior one third of his tongue. No history or clinical

Figure 35.16 Oral cancer of lateral border of tongue. Note red and white areas of lesion. (See color insert.)

signs of trauma were present. Palpation of the floor of the mouth and cervical triangles did not reveal enlarged lymph nodes. It was agreed that an excisional biopsy of the area be performed, and the lesion was removed in toto. Histologic examination revealed a well-differentiated carcinoma in situ. The area healed without incident and the patient was placed on a 2-month recall.

The median age of diagnosis of oral cancer is 64 years.

It comprises approximately 3% of all cancers (31,000 cases per year). Of note is the fact that the 5-year survival rate of 50% has not improved to any extent over the past 30 years. The highest incidence is in African American men, followed in order by white men, African American women, and white women. Early detection, diagnosis, and treatment of stage I and II lesions are associated with improved recovery and survival. Over 90% of head and neck cancers are squamous cell carcinomas. Tobacco and alcohol use are the major risk factors. Smokers have a

Figure 35.15 Advanced oral cancer of lower lip. (See color

Figure 35.17 Oral cancer of posterior tongue/lingual tonsil.

insert.)

(See color insert.)

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TABLE 35.2 DIFFERENTIAL DIAGNOSIS OF OROFACIAL PAIN IN OLDER ADULTS

Odontogenic (Dental) Pain

Fractures Eagle Syndrome Sinusitis

Migraine

Cluster Headache

Temporomandibular Disorder

Temporal Arteritis

Neuralgias Trigeminal Glossopharyngea Postherpetic Neuralgia Tension-Type Headache

Atypical Facial Pain

Neoplastic Pain

Cervical Arthritis Carotidynia

Cardiac Pain (Angina)

Gastrointestinal Pain

Psychological Pain

TMJ, temporomandibular joint.

Eliciting/Accompanying Factors

Character of Pain

Duration of Pain

May be intermittent or continuous Spontaneous in nature May be affected by temperature or pressure on offending tooth Associated with atrophic bone, usually mandibular Mineralization of stylohyoid ligament Surgical correction necessary Change in head position Valsalva maneuver Pain involving the posterior maxillary dentition Usually unilateral Spontaneous onset Nausea and vomiting Sensoriphobia High prevalence in men Spontaneous, repetitive, seasonal (?)

Tearing, ptosis, nasal obstruction Occurs at same time of day, often during sleep History of trauma and/or bruxism Trismus Deviation TMJ sounds/pain on palpation Dental occlusal discrepancies Pain in the scalp (when combing hair) Orbital pain Claudication of the masticatory muscles Sudden onset Sudden onset Trigger point in dermatome of affected nerve Previous herpes zoster infection May be scarring Usually bilateral Nausea and vomiting are rare May be related to stress, anxiety and depression ‘‘Wastebasket’’ term Usually unilateral and continuous May spread to a large area of the face Relationship between the pain source and site may be absent Caused by pressure on a cranial nerve, ulceration, and/or infection May be accompanied by paresthesia Chronic neck pain Confirm diagnosis with imaging Inflammation of the carotid bulb Anti-inflammatory medications are effective Pain on exertion radiating to lower and rarely upper jaw May also occur at rest Epigastric in location May be similar to cardiac pain in distribution Often associated with depression Distribution may not follow known pathways

Dull, aching, throbbing, lancinating Mild/moderate/severe

Brief—minutes/hours

Sharp, ache, deep

Short—hours/days

Sharp pain related to head movement Mild/moderate/severe Nonpulsating, aching, pressure Mild/moderate/severe

Long—weeks/months

Throbbing Severe

Short—hour/days

Boring, sharp, burning, excruciating Severe

Brief—minutes/hours

Dull ache Mild/moderate/severe

Long—weeks/months

Deep, aching, throbbing, burning Moderate/severe

Short—hours/days

Sharp, knife-like, sudden, excruciating, lancinating Severe Mild/moderate/severe

Very brief—seconds (may be recurrent)

Dull, nonpulsating, pressure, tightness Mild/moderate

Short—hours/days

Constant, pulling, deep, aching Mild/moderate/severe

Long—weeks/months

Sharp, knife-like Moderate/severe

Long—weeks/months

Ache, sharp Mild/moderate/severe Tenderness on palpation, pain on affective side of neck Mild/moderate/severe Sharp, deep, pressure Moderate/severe

Long—weeks/months

Short—days

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Long—weeks/months

Long—weeks/months

Short—minutes

Burning, dull Moderate/severe

Short—minutes/hours

Vague, dull, ache Mild/moderate/severe

Long—weeks/months/years

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ORAL MUCOSITIS CASE SEVEN

Figure 35.18 Advanced oral cancer of floor of the mouth. (See

A dental consult was requested for Mr. G., a 58-year-old with a diagnosis of stage IV non-Hodgkin lymphoma who was admitted for chemotherapy and bone marrow transplant. His chief oral complaint was of pain and burning of the oral tissues. Oral examination revealed diffuse ulcerative lesions, primarily of the buccal and labial mucosae. A diagnosis of mucositis secondary to cancer chemotherapy was made. Treatment with aminacrine (Kamillosan) liquid has been shown clinically to resolve ulcerated areas within 24 to 36 hours, so this was ordered for Mr. G.

color insert.)

five to nine times greater risk than nonsmokers, and snuff users have a four times greater risk. Moderate-to-heavy alcohol users have been shown to have a three to nine times greater risk of developing oral cancer in studies controlled for tobacco use. Recent findings have found an association between the human papilloma virus and some oral cancers.

Signs and symptoms can be variable. Lesions can be ulcerative, erythematous, and/or leukoplakic and are found on the tongue, especially the posterior one third of the lateral border, floor of the mouth, buccal mucosa, gingiva, lips, oropharynx, retromolar pad, and palate (see Figs. 35.15 through 35.18). Pain may not be associated with early lesions but is usually present in advanced cases. Paresthesia may be a sign of neural involvement.

Untreated lesions often spread to the lymphatic system of the head and neck, clinically producing enlarged lymph nodes. Verrucous carcinoma (comprising approximately 3% of all oral cancers) is a slow growing, diffuse, white thickening of the buccal mucosa, buccal vestibule, edentulous alveolar ridge, and/or gingival. It is often associated with smokeless tobacco use, is well differentiated and has a much better prognosis than typical squamous cell carcinoma.

Surgical management is most often the primary treatment, followed by radiation, chemotherapy, or any combination of the three. If a lesion is discovered, a conventional biopsy with histologic examination of the tissues is the most reliable means of diagnosis. Superficial lesions can be managed with local excision and regular follow-up. Invasive lesions should be managed through a multidisciplinary approach. Imaging studies will aid in the diagnosis and determination of treatment methods. Five-year survival rates are improved in patients with clear surgical margins, welldifferentiated cell type, early staging, and negative nodes.

The high risk of second primary lesions mandates close monitoring for a minimum of 5 years following initial tumor resolution.

Tissue destruction and altered functional abilities of the oral cavity following radiation therapy and/or chemotherapy results in oral mucositis. Oral mucositis is characterized by inflammation and ulceration of the oral mucosa secondary to destruction of the squamous epithelium, vasculature, connective tissue, salivary glands, muscle, and bone. It occurs in 60% to 92% of patients undergoing these therapies. The severity of the mucositis is related to the cumulative dose and type of fraction schedule for radiation therapy, timing and type of chemotherapy, type of tissue irradiated, location of radiation field, and local factors, including preexisting dental conditions, presence of irritating substances (i.e., alcohol, tobacco), and age.

Signs and symptoms of oral mucositis are pain, difficulty in mastication, dysphagia, malnutrition, dehydration, infection (especially candidiasis), and taste alteration.

Management of this condition is preventive and symptomatic. Dental treatment prior to the initiation of radiation and/or chemotherapy to eliminate infection and restore good oral health will markedly reduce the risk of oral complications. Regular dental evaluations during and following cancer treatment will help prevent severe complications.

Proper oral hygiene and use of topical fluorides will help minimize dental caries and periodontal disease. Use of aminacrine (Kamillosan) liquid or analgesic and anesthetic oral rinses will help reduce the pain associated with oral mucositis and aid in nutritional intake. Palifermin (Kepivance), a recombinant human keratinocyte growth factor, has been shown to decrease the incidence and duration of severe oral mucositis in patients with hematologic cancers undergoing chemotherapy, with or without radiation, followed by a bone marrow transplant.

ORAL CANDIDIASIS CASE EIGHT Miss H. is a 77-year-old with a medical history significant for moderately well-controlled type 2 diabetes mellitus,

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Figure 35.19 Candidiasis of lateral border of the tongue. (See

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Figure 35.20 Candidiasis of soft palate. (See color insert.)

color insert.)

moderate obesity, and moderate asthma. Her medications included glyburide 15 mg per day and albuterol inhaler one to two puffs q4–6h. Miss H. presented with a 2-day history of moderate pain and mild swelling of the mandibular right buccal vestibule associated with a periodontally involved mandibular right second molar. After the affected area was incised and drained under local anesthesia, the patient was placed on amoxicillin 250 mg. t.i.d. for 10 days. Three days later, Miss H. presented with a chief complaint of a sore mouth with white patches on her tongue and the inside of her cheeks. Examination of the mouth revealed diffuse white papular areas that were easily removed with a tongue blade, leaving a bleeding mucosal surface. A clinical diagnosis of candidiasis was made and the patient was prescribed a 14-day course of nystatin oral suspension (400,000 units q.i.d.) to be rinsed for 1 minute and swallowed. Resolution of the mandibular swelling and the candidiasis was evident at the reexamination of the patient 1 week later.

Candida sp, is often the cause of angular cheilitis (inflammation and tissue breakdown at the corners of the mouth).

Diagnosis is by history, clinical signs and symptoms, and a positive cytologic smear, culture, or biopsy.

Management of uncomplicated candidiasis is with any number of topical antifungal medications, including nystatin oral suspension (200,000 to 400,000 units q.i.d.) rinsed and swallowed. Other antifungal medications include clotrimazole and fluconazole. Patients with dentures should be instructed to remove the dentures before the antifungal treatment is administered. The dentures are then to be thoroughly cleaned and soaked in an effective disinfectant or antifungal medication, as the prosthesis will harbor the organism and may result in reinfection of the oral tissues if inserted into the mouth untreated. In patients with systemic infections or compromised immunity, administration of amphotericin B, which requires intravenous administration, may be necessary. Angular cheilitis may be treated with nystatin ointment or clotrimazole cream.

TRAUMATIC LESIONS Candidiasis is the most common fungal infection to affect the oral cavity. Candida sp is a normal component of the oral flora, and most infections caused by these organisms are opportunistic. It is common in patients who wear dentures, have poor oral hygiene, have nutritional deficiencies, and are xerostomic, immunocompromised, debilitated, or receiving prolonged antibiotics and/or oral inhalants. Oral candidiasis may be the result of the compromised medical condition of the individual, from the therapeutic management of the patient or a combination of both.

Signs and symptoms may vary from being totally asymptomatic to having a burning or painful complaint with no overt signs, to having a white coating on the oral mucosa that when wiped away reveals raw, bleeding areas (see Figs. 35.19 and 35.20). Systemic candidiasis may affect the mucosal lining of the esophagus and pulmonary tract.

CASE NINE Mrs. T., a 61-year-old with a 35-year history of multiple sclerosis, was referred by her neurologist for evaluation of self-inflicted oral trauma caused by uncontrolled movements of the head and neck resulting in constant biting of her buccal mucosae and tongue. This activity caused painful ulcerations of the oral tissues preventing normal eating and speaking. Physical examination confirmed the presence of uncontrollable, irregular movements of her head and mandible that caused the oral structures to be trapped between her teeth and form the traumatic lesions. Intraoral examination revealed several macerated ulcerations and hyperkeratotic areas on the lateral borders of the tongue and buccal mucosae.

Reduction of the movements and subsequent self-inflicted oral trauma were obtained by applying a

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Traumatic injury to the oral mucosa in the elderly patient may be due to any number of causes, including cheek, lip, or tongue biting, ill-fitting dentures, fractured teeth or dental restorations, improper brushing of teeth and/or flossing, or dysfunctional motor activity.

Signs and symptoms are typically painful, ulcerated areas with erythematous borders and/or hyperkeratotic areas. Often these lesions present in a similar manner as do more serious conditions, including squamous cell carcinoma, and the transient nature of traumatic lesions must be recognized to avoid misdiagnosis and unnecessary treatment.

Management of traumatic lesions includes the identification and elimination of the cause and subsequent evaluation of the healing of the area. If no or limited resolution of the traumatic lesion occurs after an adequate healing period (2 to 4 weeks in an elderly patient), then further testing, including biopsy, is recommended.

BURNING MOUTH SYNDROME (STOMATOPYROSIS) CASE TEN

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cervical collar, which reduced the head movements, and a flat occlusal splint, which prevented the soft tissues from becoming trapped between the teeth. Healing of the lesions occurred over the 3 weeks following intervention.

Reexamination of the patient 7 months later demonstrated a significant decrease in traumatic injury to the oral tissues and a corresponding improvement in eating and speech.

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Mrs. W., a 67-year-old, presented with a 2-month history of burning pain of the mouth, primarily of the tongue, that was absent on waking but presented and increased in intensity over the course of the day. She identified the intensity of her oral pain at four on the Visual Analog Scale. Intraoral examination was within normal limits.

Medical history was remarkable for anxiety and depression. Laboratory findings were normal. No definitive cause was identified. Treatment was palliative and consisted of a rinse comprised of equal parts of diphenhydramine (Benadryl) elixir and attapulgite (Kaopectate), which resulted in mild relief. Reports on subsequent follow-up examinations demonstrated variable intensity in symptoms, with no evident cause and effect.

While burning mouth syndrome (BMS) has no identifiable etiology, it has been associated with various nutritional deficiencies, anxiety, depression, type 2 diabetes mellitus, salivary flow changes, allergic reactions, candidiasis, dentures, and/or parafunctional behavior. BMS is often diagnosed in postmenopausal women. However, no condition has been definitely linked to BMS. Detailed oral and systemic clinical, radiographic, and

laboratory evaluation of the patient may not often specify a cause.

Signs and symptoms are generally the occurrence of burning pain localized to the tongue and, infrequently, other oral soft tissues with normal mucosal findings.

There are reports that BMS patients demonstrate the same personality characteristics seen in other chronic pain patients.

Management should be tailored to each patient and may be multidisciplinary in nature. Palliative treatment includes topical analgesic rinses (see section ‘‘Oral Mucositis’’) and/or chronic pain protocols.

ORAL CONDITIONS AND SYSTEMIC DISEASE Millions of older people have complex medical conditions that have an adverse effect on oral health. The incidence of compromised oral health is increasing due to advancing age, medical health, complications of medical treatment, and lack of oral health care, particularly in the institutional setting. As the current population continues to age, these problems will place a significant strain on health care providers and systems. An association between oral conditions and systemic disease has been demonstrated in a large number of epidemiologic studies regarding older individuals. Periodontal disease in particular has been linked to aspiration pneumonia, atherosclerosis, cardiovascular diseases, stroke, diabetes mellitus, and arthritis.

PERIOPERATIVE CONSIDERATIONS Physicians are often consulted by dentists regarding antibiotic prophylaxis and anticoagulation considerations.

Current American Heart Association/American Dental Association recommendations call for antibiotic prophylaxis in high-risk cardiac conditions when selective invasive dental procedures are performed. Prevention of infection of prosthetic joints is recommended by the American Academy of Orthopedic Surgeons/American Dental Association when: 1. an invasive dental procedure is to be performed; 2. the prosthetic joint is within 2 years of placement; 3. the patient has had previous prosthetic joint infections; and/or 4. the patient is immunocompromised.

Many dental procedures may be safely performed on patients receiving anticoagulant therapy within therapeutic international normalized ratio (INR) levels. Interruption of anticoagulant therapy should be on the basis of the invasiveness of the dental procedure, the risk of abnormal bleeding, and the risk of thromboembolism in the absence of anticoagulant therapy. It is recommended

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that a current INR level be available prior to any invasive procedure.

Recommendations regarding these clinical concerns are reviewed periodically and the reader is advised to refer to the most current literature on the subject (please refer to American Dental Association citations in ‘‘Selected Reading’’).

ATHEROSCLEROSIS, CARDIOVASCULAR DISEASE, AND STROKE CASE ELEVEN Mr. S., a 75-year-old, presented for fabrication of maxillary and mandibular complete dentures following the removal of his remaining natural teeth due to severe periodontal disease. Medical history included a long-term history of smoking, myocardial infarction following unstable angina, for which quadruple coronary bypass surgery was performed, and light-headedness on standing, which was being managed with meclizine. A screening panoramic radiograph revealed bilateral radiopacities inferior to the mandible at the level of C3 and C4 vertebral bodies, consistent with calcification affecting the carotid arteries. Subsequent referral and sonographic evaluation revealed extensive arthrosclerotic changes and severe bilateral carotid stenosis, 90% of the right external and internal carotid arteries, 70% of the left internal carotid artery, and 55% of the left external carotid artery. Carotid digital subtraction angiography demonstrated a stenosis >95% at the origin of the right internal carotid artery for a 2.5 cm. segment. The left internal carotid showed a 65% stenosis. The patient underwent right carotid endarterectomy with a satisfactory outcome.

Several recent studies have implicated chronic inflammatory conditions, including periodontitis, with atherosclerosis after adjusting for other common risk factors. Poor oral health, especially when in combination with smoking, is a risk factor for death due to cardiovascular disease and cerebrovascular accidents. Periodontitis has been shown to elevate levels of C-reactive protein and fibrinogen, reliable markers for atherosclerosis. Specific oral bacteria associated with periodontitis have been demonstrated in atheromas in coronary vessels. Signs of carotid calcifications on panoramic radiographs are highly associated with positive ultrasound readings, and the extent of carotid calcifications and the severity of periodontal disease have been shown to be related. In fact, successful treatment of periodontitis has been shown to reduce the levels of inflammatory markers associated with increased risk of cardiovascular and peripheral arterial disease. While the effects of periodontitis may have occurred over many years and are often most severe in elderly patients, it is important to treat existing periodontal disease, eliminate chronic inflammation, and minimize additional local and systemic damage.

487

DIABETES CASE TWELVE Ms. H., a 73-year-old, presented for comprehensive dental care. Medical history was significant for long-term (39 years) poorly controlled insulin-dependent diabetes, congestive heart failure, myocardial infarction (age 64), and peripheral artery disease. Oral evaluation revealed multiple missing teeth and severe periodontitis and alveolar bone loss associated with the remaining natural teeth. Removal of hopelessly involved teeth and initiation of proper oral hygiene, including frequent professional oral prophylaxis, and partial denture fabrication improved the patient’s oral health, allowing for improved food selection, enhanced nutritional intake, and normal glucose levels.

Diabetes and periodontitis have a mutually deleterious effect on one another. Poorly controlled diabetes has been associated with a three times greater incidence of periodontal disease, and the duration of diabetes is related to the severity of periodontitis. Degenerative vascular changes, impairment of the immune system, and altered metabolism caused by diabetes contribute to impaired synthesis of collagen and impaired wound healing, predisposing factors to periodontitis.

Periodontitis, because of the release of inflammatory proteins into the circulation, can result in altered insulin function and increased glucose levels. The highly inflamed gingival tissues associated with periodontitis may allow bacteria and inflammatory mediators to readily enter the blood stream and negatively affect normal insulin activity. Good oral health allows proper mastication, selection of healthy foods, and improved nutrition. It appears that proper management of periodontal disease and the subsequent elimination of chronic inflammation has a positive effect on the control of glucose levels in the patient with diabetes.

ASPIRATION PNEUMONIA/CHRONIC OBSTRUCTIVE PULMONARY DISEASE CASE THIRTEEN Mr. F., an 80-year-old with a 42-year history of hereditary spastic paraparesis and periodontitis associated with poor oral hygiene, progressively developed significant dysphagia over the past 10 years. He has been tube fed for 2 years. Over the past 10 months, he has had three episodes of pneumonia, the last two resulting in admission to the intensive care unit. Bacterial isolates from sputum samples identified several oral pathogens, including Actinobacillus actinomycetemcomitans, a bacterium commonly associated with periodontal disease. Recovery from each episode was prolonged and had residual effects on the patient’s swallowing ability.

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Proper oral hygiene was instituted to reduce the bacteria-harboring plaque associated with his remaining teeth. However, his dysphagia progressed to the point that a gastrostomy tube was placed to allow proper nutrition and prevent aspiration.

Dental plaque may serve as a reservoir for oral and respiratory bacteria and may be the cause of aspiration pneumonia in elderly individuals, particularly those with dysphagia. Patients with significant dental plaque accumulations in nursing home facilities and hospitals are at greater risk for nosocomial infection, as it has been shown that the dental plaque of these patients has become colonized with respiratory organisms. Recurrent aspiration may introduce these pathogens into the respiratory tract and cause pneumonia. Poor oral health has been identified as a risk factor for aspiration pneumonia. Institution of proper oral hygiene, including the use of a daily rinse containing 0.12% chlorhexidine gluconate, has been shown to reduce the rate of pneumonia by 40% to 50%.

Some evidence exists that associates periodontal disease with chronic obstructive pulmonary disease (COPD).

Aspiration of saliva containing respiratory pathogens, enzymes, and host-derived mediators may cause lung inflammation and infection in the lower airway, leading to exacerbation of COPD and diminished respiratory function and disease progression. Reduction of bacteria-harboring dental plaque by improvement of oral hygiene may prevent the aspiration of significant numbers of these pathogens, reducing the incidence of pneumonia, and subsequent worsening of COPD.

DEMENTIA CASE FOURTEEN Ms. K., a 71-year-old with a 4-year history of rapidly progressing Alzheimer disease (AD), was evaluated at the request of her caregiver. With mild restraint of the patient’s head, visual oral examination of her dentition was possible. Significant accumulations of dental plaque covered her teeth; however, multiple carious lesions were visible involving the coronal and root surfaces of the teeth. Prior to the onset of AD, the patient had meticulous oral hygiene and was caries-free for 20 years.

Management of the patient was not possible in the conscious state. After consultation with her caregiver, who was her health care proxy, it was decided to treat Ms. K. in the operating suite utilizing general anesthesia.

Multiple dental restorations were performed to maintain several reasonably healthy teeth, preserve some masticatory function, and prevent making the patient completely edentulous. Most of her teeth, however, required extraction due to extensive dental decay. The patient tolerated the procedure without incident. Proper

oral hygiene and topical fluoride programs were started by her caregiver, reducing the accumulation of dental plaque and the rate of dental caries.

Individuals with dementia have been shown to have a higher incidence of oral diseases. Several longitudinal studies conclude that the rate of oral conditions appears to be related to dementia severity, not the specific dementia diagnosis. The heavy dental plaque accumulation, directly related to poor or absent oral hygiene, is associated with the development of dental caries. As noted in the preceding text, dental plaque also predisposes the patient to aspiration pneumonia and cardiovascular disease. Patients with dementia also have decreased use of dentures and increased denture-related oral conditions, and they visit a dentist less frequently than those without dementia.

Dental management is difficult in those with severe dementia. Attention should be given to oral hygiene, avoiding medications with a xerostomic effect, removal of unrestorable teeth, frequent oral examination, and aggressive topical fluoride programs. Oral or intravenous sedation or general anesthesia may be necessary to provide adequate dental care.

CONCLUSION The health of the hard and soft tissues of the oral cavity directly affects the systemic health of an individual. This is particularly true in elderly people, who have limited functional capacity and a compromised response to challenges affecting general health. Oral health is essential for proper nutrition, positive self-image, and favorable quality of life. Prevention of several fatal systemic conditions is directly related to proper oral hygiene and the maintenance of oral health. Physicians are encouraged to routinely examine the oral cavity and take steps to promptly intervene when abnormal findings are identified.

SELECTED READING Abdollahi M, Radfar M. A review of drug-induced oral reactions.

J Contemp Dent Pract. 2003;3(4)1:010–031.

American Academy of Oral Medicine. Clinician’s guide to oral health in geriatric patients. Baltimore, MD; 1999a.

American Academy of Oral Medicine. Diagnosis and treatment of chronic orofacial pain. Baltimore, MD; 1999b.

American Dental Association; American Academy of Orthopedic Surgeons. Antibiotic prophylaxis for dental patients with total joint replacements. J Am Dent Assoc. 2003;134(7):895–899.

American Dental Association; American Heart Association. Prevention of bacterial endocarditis: Recommendations by the American Heart Association by the committee on rheumatic fever, endocarditis and kawasaki disease. JAMA. 1997;277:1794–1801.

Beers MH, Berkow R, eds. The merck manual of geriatrics, 3rd ed.

Whitehouse, NJ: Merck Research Laboratories; 2000.

Chiappelli F, et al. Dental needs of the elderly in the 21st century. Gen Dent. 2002;50(4):358–363.

Ciancio SG, ed. American Dental Association to Dental Theraputics, 3rd ed. Chicago, IL: ADA Publishing; 2004.

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Munksgaard: Munksgaard Publishing; 1996.

Jakobsson U. Pain management among older people in need of help with activities of daily living. Pain Manag Nurs. 2004;5(4):137–143.

Lamster IB. Oral health care services for older adults: A looming crisis.

Am J Public Health. 2004;70(9):14–17.

Navazesh M. Dry mouth: Aging and oral health. Compend Contin Educ Dent. 2002;23(10 suppl):41–48.

Neville BW, Day TA. Oral and precancerous lesions. CA Cancer J Clin.

2002;52(4):195–215.

Rankin KV, Jones DL, Redding SW, eds. Oral health in cancer therapy: A guide for health care professionals, 2nd ed. Dallas, TX: Dental Oncology Education Program; 2003.

Scannapieco FA, Bush RB, Paju S. Associations between periodontal disease and risk for atherosclerosis, cardiovascular disease and stroke. A systemic review. Ann Periodontol. 2003a;8(1):38–53.

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Scannapieco FA, Bush RB, Paju S. Associations between periodontal disease and risk for nosocomial bacterial pneumonia and chronic obstructive pulmonary disease. A systematic review. Ann Periodontol. 2003b;8(1):54–69.

Spielberger R, et al. Palifermin for oral mucositis after intensive therapy for hematologic cancers. N Engl J Med. 2004;351(25):2590–2598.

Vernillo AT. Dental considerations for the treatment of patients with diabetes mellitus. J Am Dent Assoc. 2003;134(10 suppl):24S–33S. Wayne DB, Trajtenberg CP, Hyman DJ. Tooth and periodontal disease: A review for the primary-care physician. South Med J. 2001;94(9):925–932.

Williams RC. A century of progress in understanding periodontal disease. Compend Contin Educ Dent. 2002;23(5 suppl):3–10.

Wisconsin Geriatric Education Center. Geriatric oral health: The missing link to comprehensive care. http://www.cuph.org/wgec/index.jsp (Accessed August 23–28, 2004).

Wong-Baker FACES Pain Rating Scale. http://www.ndhcri.org/pain/ Tools/Wong-Baker Faces Pain Rating Scale.pdf (Accessed February 24, 2005).

Rosenthal ch35.tex

Queries in Chapter 35 AQ1. We have removed the possessive form of syndromes, diseases for ‘Alzheimer disease’ Hodgkin lymphoma, Sjögren syndrome, Parkinson disease, Wharton ducts, Stensen duct, Ludwig angina, Wharton ducts, and ‘Eagle syndrome’ as per the requirement of the house style. Please confirm whether this is fine.

AQ2. We have renumbered the tables and figures in this chapter. Please confirm whether this fine.

AQ3. As per the style of this book, the generic names for the drugs should be mentioned. We have therefore included the generic name ‘attapulgite’ before the trade name ‘Kaopectate’. Please confirm if this is fine.

AQ4. As per the style of this book, the generic names for the drugs should be mentioned. We have therefore included the generic name ‘Aminacrine’ before the trade name ‘Kamillosan’. Please confirm if this is fine.

AQ5. As per the style of this book, the generic names for the drugs should be mentioned. We have therefore included the generic name ‘Nystatin lozenge’ before the trade name ‘Mycostatin pastilles’. Please confirm if this is fine.

AQ6. Please confirm whether the second instance of ‘‘A’’ can be deleted for ‘‘Nystatine lozenge’’.

AQ7. This sentence appears to be incomplete. Please provide the completed sentence.

AQ8. Please confirm as to what this ‘?’ indicates.

AQ9. As per the style of this book, the generic names for the drugs should be mentioned. We have therefore included the generic name ‘aminacrine’ before the trade name ‘Kamillosan’. Please confirm if this is fine.

AQ10. Did you intend to say ‘unremarkable’ here?

AQ11. As per the style of this book, the generic names for the drugs should be mentioned. We have therefore included the generic name ‘diphenhydramine’ before the trade name ‘Benadryl’. Please confirm if this is fine.

AQ12. As per the style of this book, the generic names for the drugs should be mentioned. We have therefore included the generic name ‘attapulgite’ before the trade name ‘Kaopectate’. Please confirm if this is fine.

AQ13. We have expanded ‘‘INR’’ as ‘‘international normalized ratio’’.

AQ14. We have changed ‘SUGGESTED READINGS AND RESOURCES’ to ‘SELECTED READING’ to match the house style. Please confirm whether this is fine AQ15. What does this number denotes?

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AQ16. Please provide the publisher’s name for this reference.

AQ17. Please provide the publisher’s name for this reference.

AQ18. The style of this book demands that ‘et al’ follows the names of at least three authors. Only one name has been provided for this references. Please provide two other names for this same. Chiappelli, Ciancio, Helgeson, and Spielberger.