common oral conditions in older persons

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Common Oral Conditions in Older PersonsWanda C. Gonsalves, Md, Medical University of South Carolina, Charleston, South Carolina

a. stevens WriGhtson, Md, University of Kentucky College of Medicine, Lexington, Kentucky robert G. henry, dMd, MPh, Veterans Affairs Medical Center and University of Kentucky College of Dentistry, Lexington, Kentucky

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Older persons are at risk o chronic diseases o the mouth, including dental in ections (e.g., caries, periodontitis),tooth loss, benign mucosal lesions, and oral cancer. Other common oral conditions in this population are xerostomia(dry mouth) and oral candidiasis, which may lead to acute pseudomembranous candidiasis (thrush), erythematouslesions (denture stomatitis), or angular cheilitis. Xerostomia caused by underlying disease or medication use may betreated with over-the-counter saliva substitutes. Primary care physicians can help older patients maintain good oralhealth by assessing risk, recognizing normal versus abnormal changes o aging, per orming a ocused oral examina-tion, and re erring patients to a dentist, i needed. Patients with chronic, disabling medical conditions (e.g., arthritis,

neurologic impairment) may bene t rom oral health aids, such as electric toothbrushes, manual toothbrushes with wide-handle grips, and foss-holding devices. ( Am Fam Physician. 2008;78(7):845-852. Copyright © 2008 AmericanAcademy o Family Physicians.)

▲ Editoria : “PromotingOral Health: The FamilyPhysician’s Role,” p. 814.

Downloaded from the American Family Physician Web site at www.aafp.org/afp. Copyright ©2008 American Academy of Family Physicians. For the private,



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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationsEvidencerating References

Fluoride gels, rinses, and varnishes may prevent or reduce root caries. C 7Patients with xerostomia should be encouraged to drink water, avoid

alcohol and oods and drinks that contain sugar, and use over-the-counter saliva substitutes as needed.

C 19

Topical anti ungal therapies are e ective or treating denturestomatitis and angular cheilitis caused by candidiasis.

A 17

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For informationabout the SORT evidence rating system, go to http://www.aafp.org/afpsort.xml.

Tab e 1. Common Ora Conditions in O der Persons

Condition Clinical presentation Treatment Comments

Dental caries 1-6 Coronal (above the gum) or root:pain ul brownish discolorationwith cavitation

Root caries may be treated with uoridegels, varnishes, or toothpaste; e ective

or some shallow caries

In ection can be reducedwith good oral hygieneand pro essional dentalcare; patients shouldavoid sugary oods anddrinks; see Table 2 orrisk actors

Gingivitis7 Red, swollen, bleeding gums Good oral hygiene, including brushingand ossing daily

—

Periodontitis 6,8-12 Gingivitis, gingiva recession,loose or shi ting teeth

Good oral hygiene, including brushingand ossing daily; dental scalingper ormed by a dental healthpro essional; adjunct antibiotic therapy

Associated withcardiovascular disease,worsening diabetes, andaspiration pneumonia

Xerostomia 7,13 Swollen, dry, red tongue;burning sensation; di fcultywith speech and swallowing;change in taste

Saliva substitutes; sugar- ree gum orpilocarpine (Salagen) and cevimeline(Evoxac) drops may stimulate salivaproduction

See Table 3 or riskactors

Candidiasis 14-17 Acute pseudomembranous(thrush): adherent whiteplaques that can be wiped o

Erythematous (denturestomatitis): red macular lesions,o ten with a burning sensation

Angular cheilitis: erythematous,scaling fssures at the corners othe mouth

Topical anti ungals (e.g., nystatin oralsuspension or troche [Mycostatin;brand no longer available in the UnitedStates]; clotrimazole troche [Mycelex])

Or Systemic anti ungals (e.g., uconazole

[Di ucan]; ketoconazole [Nizoral;brand no longer available in the UnitedStates]; itraconazole [Sporanox])

Diagnosis can beconfrmed with oralex oliative c ytology(stained with periodicacid-Schi or potassiumhydroxide), biopsy, orculture

Denturestomatitis 18,19

Varying erythema, occasionallyaccompanied by petechialhemorrhage; localized to thedenture-bearing areas o theremovable maxillary prosthesis;usually asymptomatic

Removal o dentures at night; topicalanti ungals (see Candidiasis) placedinside the denture-ftting sur ace

Dentures should beremoved and cleaned atleast once daily

Oral cancer 20 Nonhealing ulcer or mass Re er or biopsy, staging, surgery, andother treatment

—

Information from references 1 through 20.



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Ora Hea th Assessment Too for Denta Screening

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Figure 1. Oral health assessment tool. This assessment may be completed by a non-dental pro essional at a residentialcare acility.Interpretation: Any category that has changed should be reevaluated after two weeks , and follow-up should be performed to ensure that the changes returnto normal over time. If the changes do not return to normal or if there is any unhealthy area, the patient should be referred to a dentist for a comprehensiveevaluation. Training assistance for the use of this screening tool is available at http://www.healthcare.uiowa.edu/igec/e-learn_lic/dentistry/default.asp.

Adapted with permission from Chalmers JM, King PL, Spencer AJ, Wright FA, Carter KD. The oral health assessment tool—validit y and reliability. Aust Dent J.2005;50(3):197.



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Tab e 2. Risk Factors for DentaCaries in O der Persons

Decreased salivary ow rateHistory o cariesInstitutionalizationLack o routine dental care

Low socioeconomic statusNon uoridated community water supplyPoor oral hygiene

Information from reference 13.

Figure 2. Age-related teeth yellowing andgingival recession.

Figure 3. Root caries: gingival recession anddecay (black discoloration) on root sur aces.

Figure 4. Gingivitis: erythema along toothmargins and gingival in ammation betweenteeth.



Ora Conditions

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PERIODONTITIS

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Tab e 3. Risk Factors for Xerostomia

Head or neck radiationHuman immunodefciency virusMedication use

Angiotensin-converting enzyme inhibitorsAlpha and beta blockersAnalgesicsAnticholinergicsAntidepressantsAntihistaminesAntipsychotics

AnxiolyticsCalcium channel blockersDiureticsMuscle relaxantsSedatives

Salivary gland aplasiaSjögren syndromeSmoking

Adapted from Douglass AB, Douglass JM, Barr C. OralHealth. Leawood, Kan.: American Academy of Fam-ily Physicians; 2004, with additional information fromreference 13.

Figure 5. Severe periodontitis: gingival in am-mation and recession, plaque ormation, andtooth loss.



Ora Conditions

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Figure 8. Angular cheilitis: erythematous fs-sures at the corners o the mouth that areassociated with Candida albicans or Staphy-lococcus aureus in ection.

Figure 7. Denture stomatitis: erythematousand edematous tissue on the hard palatebelow the dentures that is associated withcandidiasis.

Figure 6. Acute pseudomembranous candidi-asis (thrush): thick, curd-like plaques on buc-cal mucosa that can be removed with gauzeor tongue blade.



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The authors thank Jennie Ariail, PhD, Center for AcademicExcellence, Medical University of South Carolina, for herassistance in preparation of the manuscript.

The AuthorsWANDA C. GONSALVES, MD, is an associate professor of family medicine at the Medical University of South Carolina,Charleston. She received her dental hygiene degree from theUniversity of Louisville (Ky.) and her medical degree from

the University of Kentucky College of Medicine, Lexington,where she also completed a family medicine residency.

A. STEVENS WRIGHTSON, MD, is an assistant professorat the University of Kentucky Department of Family andCommunity Medicine and works with the department onoral health education for family physicians. Dr. Wrightsonreceived his medical degree from the University of Ken-tucky College of Medicine, where he also completed hisfamily medicine residency.

ROBERT G. HENRY, DMD, MPH, is director of geriatricdental services and assistant chief of dentistry at theVeterans Affairs Medical Center in Lexington. He is alsoa clinical associate professor at the University of KentuckyCollege of Dentistry, Lexington, and is assistant directorof the Public Health Dentistry Department for the state of Kentucky. Dr. Henry received his dental degree from theUniversity of Kentucky College of Dental Medicine and hismaster’s degree from Loma Linda (Calif.) University Col-lege of Dentistry.

Address correspondence to Wanda C. Gonsalves, MD,Dept. of Family Medicine, Medical University of SouthCarolina, 295 Calhoun St., P.O. Box 250192, Charleston,SC (e-mail: [email protected]). Reprints are not avail-able from the authors.

Author disclosure: Nothing to disclose.

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Figure 9. Oral cancer: squamous cell carci-noma on the oor o the mouth.



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