Geriatric Oral Medicine

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Geriatric Oral Medicine

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Summary

Recognition and Treatment of Common Oral Lesions/Conditions in the Elderly

Common Oral Mucosal Conditions in the Elderly
Oral mucosal diseases and lesions are common in the elderly (1). Many older adults have pigmented (varices, lingual varicosities, melanotic macules), benign soft tissue (fibromas, Fordyce granules), and hard tissue conditions (exostoses, tori). Tongue conditions include geographic tongue, black hairy tongue, lingual varicosities, and atrophy of filiform and fungiform papillae (2). The tongue may be fissured, coated, or enlarged (especially in edentulous individuals). A smooth, bald, or shiny tongue can indicate a nutritional or hematological disorder (e.g. iron or folate deficiency).

A variety of vesiculobullous and ulcerative mucosal conditions affect the elderly. Many lesions are attributed to local trauma, such as denture-related irritation, accidental biting, and sharp dental and restorative surfaces. An ill-fitting denture can also cause inflammation (denture-induced stomatitis or papillary hyperplasia) and atrophy (resorption of residual alveolar ridges). Persistent low-grade irritation by an ill-fitting denture can induce a hyperplastic reaction leading to formation of an epulis fissuratum or traumatic hyperkeratosis. Oral vesiculobullous diseases in older adults include lichen planus, pemphigus vulgaris, and cicatricial pemphigoid (2). The most common condition is lichen planus, a recurrent, chronic, inflammatory, auto-immune mucocutaneous disorder that affects approximately 1% of the population of which about 35% are aged 50+ years (3). Lichenoid mucosal lesions can also be caused by a variety of medications commonly prescribed in older patients (e.g. acyclovir, gold salts, methyldopa, thiazide diuretics). Pemphigus vulgaris is a potentially serious autoimmune vesiculobullous disorder that usually affects individuals in their fifth and sixth decades of life. Cicatricial pemphigoid is another immunologically-mediated disorder that affects primarily older women. Prolonged use of dentures in any of these conditions can cause exacerbation of oral mucosal lesions. Recurrent aphthous stomatitis is less common among the elderly, however nutritional and hematological deficiencies common in older adults can predispose to recurrent ulcers (4). Erythema multiforme is also an unusual occurrence among the elderly, but can develop and persist especially in immunocompromised persons.

Oral cancer is the most significant oral mucosal disease in older adults. Incidence rates increase with age, with over 95% of all oral cancers occurring in individuals aged 45+ years (5). In 2000, 30,000 cases were diagnosed with approximately 8,000 deaths in the USA (6). The most common premalignant oral lesion is leukoplakia, and the incidence of leukoplakic lesions undergoing malignant transformation rises sharply with age. The mortality rates for oral cancer also increase with age, and are high compared to other cancers with overall 5-year survival rates of only 50% (5). Typical sites of oral malignancy in the elderly include the tongue, lips, buccal mucosa, floor of mouth, and posterior oral-pharynx. The most common risk factors are increased age, and the use of tobacco and alcohol. Approximately 90% of all oral cancers are squamous cell carcinomas, with the remaining 10% being salivary, bone, or lymphoid cancers (7). These lesions can appear as exophytic, poorly-demarcated, ulcerated, erythroplakic and/or leukoplakic masses, and metastasize to regional lymph nodes before involving distant organs.

Common Oral Infectious Diseases in the Elderly
Older adults are more susceptible to develop opportunistic oral infections due to numerous age- and disease-related changes in the oral and systemic immune systems. Viral, fungal, and bacterial organisms invade, infect, and become latent in the hard and soft tissues of the oral-pharyngeal region, predisposing a person to disseminated systemic infections (8). The most common viral infections come from the herpes family (herpes simplex virus [HSV] and varicella zoster virus [VZV]). Initial infections typically occur in childhood, and then viruses remain dormant in sensory ganglia until reactivation occurs secondary to immunosuppression, trauma, stress, sunlight, gastrointestinal disturbances, or concurrent infections. The clinical presentation in an older adult will be similar to a younger person, but lesions may persist longer due to concomitant immunocompromising conditions. Shingles or VZV is an acute condition with very painful and frequently incapacitating oral-facial lesions. The incidence exceeds 10 per 1,000 annually in adults aged 80+ years, and is most common in immunocompromised patients (9). VZV is acquired during childhood from exposure to chickenpox. It is then reactivated causing vesicular eruptions on the skin and mucous membranes in the areas following the unilateral distribution of ophthalmic, maxillary, or mandibular divisions of trigeminal sensory nerves. Post-herpetic neuralgia has dangerous sequelae, including blindness, facial paralysis, auditory deficits, and vertigo (10). It occurs more frequently in older patients; more than 50% of zoster patients over 60 years old will develop poster herpetic neuralgia which may persist for months and even years (9).

The most frequent oral fungal infection in older adults is caused by Candida albicans (11). Several oral and systemic conditions in older adults lead to fungal proliferation and subsequent development of infectious diseases. Removable dental prostheses, poor oral and/or denture hygiene, endocrine disorders (e.g. diabetes), underlying immunosuppression, nutritional deficiencies, salivary gland hypofunction, and medications (e.g. antibiotics, corticosteroids, immunosuppressants, cytotoxic agents) have all been associated with oral fungal infections. The loss of vertical dimension, and drooling problems secondary to cerebrovascular accidents, create a moist environment in the labial commissures that also favor yeast infection. The most common bacterial infections are associated with new and recurrent dental caries (e.g. Streptococcus mutans, lactobacillus), periodontal diseases (e.g. Porphyromonas gingivalis, Treponema denticola), and acute and chronic salivary infections (e.g. Staphylococcus aureus, Streptococcus viridens).

Salivary Gland Disorders in the Elderly
Salivary gland dysfunction seen in older persons can be a result of local and systemic disease, head and neck radiation treatment, chemotherapy, immunologic disorders, and prescription and non-prescription medication intake(12-14). Obstructions (due to mucous plugs or calcifications) and acute/chronic bacterial infections cause salivary dysfunction. Sjögren's syndrome is an autoimmune disease affecting exocrine glands (salivary and lacrimal) in predominantly older females, and salivary dysfunction is a common sequelae with associated complaints of dry eyes and dry mouth (15). Other systemic conditions common in the elderly such as Alzheimer's, diabetes, and dehydration have been implicated in salivary gland hypofunction. Finally, numerous prescription and non-prescription medications frequently taken by older persons cause salivary hypofunction (14). Many common drugs are antidepressants, antihypertensives, antiParkinsonian drugs, antipsychotics, antihistamines which have been reported to cause xerostomia and salivary dysfunction. Extraoral manifestations of salivary gland dysfunction include candidiasis in the labial commissures and dry, cracked lips. Parotid or submandibular enlargement with associated pain and suppuration may indicate infections or ductal obstructions. The intraoral sequelae of insufficient salivary production are dental caries, gingivitis, materia alba, candidiasis, poorly fitting dentures, dysphagia, dysgeusia, and altered mastication and deglutition (12). These oral and pharyngeal problems can have serious consequences to an older adult. Impaired food and beverage intake can result in malnutrition and dehydration. Recurrent oral infections and impaired oral immunity can lead to aspiration pneumonia and systemic opportunistic infections.

Prevention and Treatment of Oral Mucosal Conditions in the Elderly
Prevention of oral cancer begins with the elimination of established risk factors (e.g. tobacco, alcohol). Early detection and recognition through regular comprehensive extra- and intra-oral examinations in dentate and edentulous persons will enhance the prognosis and reduce the morbidity and mortality associated with cancer and its treatments (7). Oral cancer is treated by surgery, chemotherapy, and radiotherapy, which also have significant oral sequelae including stomatitis, dysphagia, dysgeusia, pain, paresthesias, facial disfigurement, oral motor dysfunction, salivary hypofunction, and an increased risk of developing osteoradionecrosis. Comprehensive dental management before, during, and after treatment is essential to prevent complications. Importantly, older edentulous individuals are four times less likely to see a dentist than dentate individuals (16), and therefore should be targeted for regular annual head and neck cancer examinations (17, 18).

Treatment of traumatic oral lesions begins with elimination of underlying factors. The most common is repair of an ill-fitting denture flange/base, or removal of an epulis fissuratum. Palliative topical medications (analgesics) are helpful, and antibiotic coverage to prevent secondary bacterial infection should be considered in the immunocompromised patient. For most oral vesiculobullous and erosive diseases, therapy depends upon the severity of the condition, ranging from mild topical steroids and oral rinses to strong topical steroids to systemic steroids with or without immunosuppressant agents (2). When high dose steroids are considered, dentists should consult with the patient's physicians, especially if an older patient has concurrent medical problems such as diabetes, coronary heart disease, hypertension, osteoporosis, or depression.

Prevention and Treatment of Oral Infectious Diseases in the Elderly
Prevention of the spread of viral lesions in the elderly can be accomplished by avoiding individuals with active infections. Herpes simplex and zoster lesions are usually self-limiting. Therefore, supportive measures are necessary to maintain adequate nutritional and fluid intake and diminish pain. However, early diagnosis can diminish morbidity in older patients. In particular, immunocompromised adults are susceptible to recurrent herpes infections, and they require immediate and aggressive antiviral treatment. Patients with renal insufficiency should receive adjusted antiviral doses (acyclovir, valacyclovir, famciclovir). Post-herpetic neuralgia requires analgesics, tricyclic antidepressants, and sometimes steroids (2).

Candidiasis prevention involves meticulous oral and denture hygiene, judicious use of antibiotics and immunosuppressants, and elimination of underlying local and systemic etiologic factors (e.g. salivary hypofunction, diabetes, immunodeficiency). Comprehensive management of oral candidiasis is usually successful with antifungal creams, rinses, and lozenges, but persistent infections require systemic antifungal agents (11, 19). Dentures are frequent sources of fungal infections, and require antifungal therapy with a 10-15 minute 1% sodium hypochlorite soak and antifungal creams during use.

Prevention and Treatment of Salivary Gland Disorders in the Elderly
Disorders of the salivary glands require accurate diagnosis in order to prevent the development of long-term oral and pharyngeal complications (20). Identifying individuals at risk for developing salivary hypofunction (e.g., those taking multiple medications with xerostomic effects, individuals with a history of head and neck radiotherapy or Sjögren’s syndrome) will also help prevent the oral sequelae of salivary disorders. Salivary gland infections require diagnostic culture and sensitivity tests, and appropriate antibiotic therapy. Amoxicillin and clavulanic acid (clindamycin if penicillin-allergic) should be immediately prescribed and monitored until the culture and sensitivity report is received. Diagnosis of salivary gland obstructions may require imaging tests (radiographs, sialograms, technetium-99 pertechnetate scans), with subsequent removal of the obstruction. Systemic diseases (e.g. Sjögren’s syndrome) should be identified, managed and controlled. In medication-associated xerostomia, drug elimination or reduction is the ideal solution in collaboration with the patient’s physician (14). However, if this cannot be achieved, substitution of one xerostomia-causing medication for another similar drug with fewer undesirable side effects or altered medication dosing schedules should be considered. For patients receiving head and neck radiation therapy for oral-pharyngeal cancers, contralateral parotid preservation techniques are effective which can help diminish post-irradiation xerostomia (21).

Patients with salivary hypofunction who have some remaining viable salivary parenchymal tissue will respond to salivary stimulants. These include sugarless candies, mints, gums, frequent use of non-sugared beverages (20), and pilocarpine (5 to 7.5 mg tid and qhs, 22, 23) or cevimeline (30 mg tid, 24). These cholinergic agonists (pilocarpine and cevimeline) are contraindicated in patients with narrow angle glaucoma, congestive heart disease, and pulmonary disease, and major side effects are sweating and diarrhea. If there is little or no remaining viable salivary gland tissue, saliva substitutes (25) and frequent intake of non-sugared beverages are necessary. In dry climates, a humidifier may also help relieve xerostomic complaints. Finally, it is vital that precautions be taken to prevent the deleterious sequelae of salivary gland dysfunction. These precautions include frequent dental recall, daily use of fluorides, brushing and flossing after each meal, and rigorous prosthesis hygiene.

Geriatric Oral Medicine

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