Oral medicine and the elderly

Xerostomia

Xerostomia or dry mouth is a common problem for many elderly people with reported prevalence estimates ranging from 12% to 47%.9 It is the most common and significant oral side-effect of medications and has been associated with more than 500 drugs.10 The impact of drug-induced xerostomia is especially evident in the elderly owing to polypharmacy, with some patients taking more than one xerostomic agent.11

Oral complications of a dry mouth include:

Lichen planus

Lichen planus is a chronic, systemic, mucocutaneous disease. Prevalence figures range from 0.1% to 4%.13 When manifesting in the oral cavity, the buccal mucosa, tongue and gingiva are the most common sites, whereas the palate is less commonly affected.14 Oral lichen planus (OLP) is a chronic condition that can persist for up to 25 years.15 Andreasen has classified oral lichen planus into six types:

These different types of OLP can co-exist in the same patient.

OLP often presents asymptomatically, however, many patients report symptoms ranging from mild discomfort to severe pain.17 Management of OLP is primarily aimed at symptomatic relief and topical corticosteroid applications are the mainstay of treatment.18 However, acute exacerbations can be treated with systemic steroids. Although the malignant potential of OLP is a controversial topic, the reported annual rate of malignant transformation for OLP is 0.27%.19 Long-term monitoring, including a minimal annual review, has been recommended.19^,21 It most commonly presents in females under the age of 60 years, however, owing to the chronic nature of the condition and the long period of monitoring required, the management of OLP extends into old age.

Vesiculobullous lesions

Pemphigus is a rare but severe auto-immune blistering disease of the skin and mucous membranes that is twice as common in females as in males.22 The pemphigus vulgaris (PV) form consists of three types:

The disease incidence is 0.75–5 cases per million per year, with a considerable geographic variability noted.23 PV can be a life-threatening condition, which results in the development of widespread painful erosions. In a recent large, population-based study carried out in the UK, the authors reported an average age of presentation at 71 years.24

Mucous membrane pemphigoid (MMP) is an auto-immune blistering condition characterized by subepithelial bullae. It is a disorder that presents in women between the ages of 51–62 years25 and, like OLP, persists into old age. The oral mucosa can often be the site of initial manifestation of MMP and can result in pain, dysphagia and peeling of the mucosa.26^,27 The intra-oral vesicles can rupture leaving persistent, irregularly shaped erosions with a yellowish slough and surrounding inflammatory halo.28 Lesions can affect any mucous membrane and skin, including the conjunctiva, nasopharynx, larynx, oesophagus, genito-urinary tract and anus.29 Complications can arise from all lesions, with life-threatening complications resulting from MMP of the larynx, oesophagus and the lower airway.30^,31

Both of these vesiculobullous conditions may be managed with topical, oral and intralesional corticosteroids,32 however, systemic immunosuppressants, such as systemic corticosteroids, along with other immunomodulatory agents, are also frequently required for disease control.33

Oral cancer

Approximately 300,000 patients worldwide are estimated to be newly diagnosed with oral cancer annually and the 5-year survival rate for oral cancer is very poor, at approximately 53%.34 Screening for this malignancy with a thorough oral examination is important as early detection can lead to an improved prognosis and an awareness of signs and symptoms will allow practitioners to identify possible malignant disease rapidly. Knowledge of potential risk factors, such as smoking and alcohol, can allow the targeted monitoring of patients at greater risk, and the dental practitioner has a central role in smoking cessation initiatives. Oral malignancy can be treated with surgery, radiotherapy, chemotherapy or a combination of these, depending on the site, extent and stage of the cancer. The role of the dental practitioner before and during the treatment of oral cancer is vital.

Before commencing treatment, detailed oral hygiene instruction should be given to the patient and, if possible, all dental treatment should be completed. Any unrestorable teeth should be extracted at least two weeks prior to the start of treatment, particularly if radiotherapy is planned. This will minimize the risk of osteoradionecrosis, which can occur if there is trauma to the mandible or maxilla in an irradiated area.35 Radiotherapy can also lead to mucositis, trismus and xerostomia.36 Radiation-induced xerostomia can have multiple manifestations, with an increase in oral infections and radiation caries.

Common oral mucosal findings

Several studies have reported that lingual varices, fissured tongue and atrophic tongue are some of the most common oral mucosal findings among elderly patients.37^,38 Lingual varices are considered to be normal structural variations in the elderly. They occur as a result of a dilatation of the veins of the tongue and are frequently seen on the ventral surface. They have been reported in up to 60% of elderly patients in both genders and their prevalence increases with age.39^,40

Fissured tongue (FT) (Figure 4) is usually characterized by a central groove with multiple laterally extending, branching fissures. It is a common clinical presentation at all stages of life. Although no definitive data exists regarding a gender predilection, it has been found in some studies to be more frequent in males,41^,42 and has been variously reported in association with:

The prevalence of FT increases markedly with age and it can be considered as an incidental finding as it is a normal manifestation of the ageing process.

Atrophic tongue (Figure 5) results from atrophy of the filiform papillae. Patients can present complaining of pain, soreness or a burning sensation in the tongue. It is commonly associated with nutritional deficiencies such as vitamin B₁₂, folate and ferritin deficiencies, and correction of these nutritional deficits can result in rapid regeneration of the papillae. Malnutrition and nutritional deficiencies such as these are prevalent and well documented in the elderly.44^,45

Denture related conditions

Although patients are now retaining more of their natural teeth, the use of removable dentures is still relatively common among older people.46 Some countries report that one-third to one-half of the older people wear full dentures, while as many as three-quarters wear removable full and or partial dentures.47^,48 Denture use raises the probability of having one or more oral mucosal lesions in the elderly.49^,50^,51 The wearing of dentures is associated with particular oral mucosal lesions, these include:

The presence of these conditions is influenced by the quality of the denture, its integrity and the oral hygiene habits of the patient.53

Denture stomatitis

Denture stomatitis is characterized by erythematous mucosa in an area commonly limited to the palatal mucosa under an upper denture. It is reported to develop in 11–67% of denture wearers54 and is more frequent in females than males.9 There are a number of factors associated with the development of denture stomatitis, such as wearing a denture continuously, smoking, dietary factors and denture cleanliness.55^,56 It is thought that the denture serves as a protective barrier for micro-organisms from the protective mechanisms of the oral cavity, such as salivary flow. It is associated with the presence of a number of organisms, the most common species isolated being Candida albicans.57 As denture hygiene and Candida albicans can both be considered causative factors in the development of denture stomatitis, the treatment includes denture care, topical and systemic antifungal preparations, or other appropriate agents if other organisms are cultured.

Angular cheilitis

Angular cheilitis is an infection in the fissures at the commissures of the mouth which are often surrounded by erythema. The lesions are frequently co-infected with both Candida and Staphylococcus aureus. Of these cases, 20% are caused by Candida albicans alone, 60% are due to a combined infection with C. albicans and S. aureus, and 20% are associated with S. aureus alone.57 Vitamin B₁₂ deficiency, iron deficiency, loss of occlusal vertical dimension and accentuated creasing at the corners of the mouth have been associated with this condition.58 Elimination or treatment of any underlying conditions that may be associated with angular cheilitis should be considered first, followed by the application of an appropriate topical agent if necessary.

Denture-related hyperplasia and traumatic ulcers

Denture-related hyperplasia often results from chronic irritation due to over extended denture margins or an ill-fitting denture. These swellings are usually firm and fibrous, but may be ulcerated and inflamed. Traumatic ulceration is not solely associated with dentures, but can also be seen due to fractured restorations or fractured teeth and sharp edges on worn teeth. Relief of any overextended areas of a denture or sharp area of a tooth, and restoration of fractured teeth, should be considered in the initial management of these traumatic lesions. In the case of hyperplastic lesions, surgical removal of the excess fibrous tissue may be required.

Burning mouth syndrome

Burning mouth syndrome is a common chronic pain disorder typically described by patients as a burning or stinging sensation of the tongue, lips or other oral mucosal surfaces without any clinical, pathological or laboratory findings.60 This condition has a prevalence of 4–5%61 and it is six times more common in women over 50 years of age than in men.62 Zakrzewska et al emphasize the importance of the use of the term syndrome as patients can present with a variety of symptoms, including:

No specific and effective means of treatment can be given to all patients with this condition and treatment interventions can range from reassurance and cognitive behavioural therapy to pharmacological interventions, including various psychotropic agents.

Trigeminal neuralgia

Trigeminal neuralgia (TN) is characterized by recurrent brief unilateral stabbing or electric shock-like pain paroxysms which are felt in the area supplied by the Vth cranial nerve, usually following light touching at a facial or intra-oral trigger point. Classically, attacks last for only a few seconds, and they are separated by a variable pain-free interval which may last for minutes, hours or days.64 Trigeminal neuralgia has a prevalence of approximately 4 in 100,000.65 It can occur in both genders, although there is a slight female predominance, and it is most commonly seen in patients over the age of 50.66 The American Academy of Neurology and The European Federation of Neurological Societies recently published guidelines for the management of trigeminal neuralgia. Carbamazepine remains as the first line treatment for the condition, with consideration given to early surgical intervention for patients with TN refractory to medical therapy.67

Giant cell arteritis

Giant cell arteritis (GCA) is the most common vasculitis of large- and medium-sized arteries that affects patients over the age of 50, with the average age of onset being 72 years old.68 Prevalence in the US of 200 per 100,000 has been reported in patients over 50,69 with an even higher occurrence of the condition in northern Europe.70^,71 It commonly presents as tenderness, swelling and headache in the temporal region, headache, jaw claudication and loss of vision. Systemic manifestations are also common with fatigue, weight loss, low-grade fever, polymyalgia rheumatica and tenosynovitis seen in more than half of patients with GCA.72 Systemic steroids are considered to be the standard treatment for patients diagnosed with GCA; the course of treatment may extend for longer than one year in a significant number of patients and the resultant problems with prolonged steroid use may be evident in this patient group.73