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The Consequences of Oral Disease in the Elderly

The Consequences of Oral Disease in the Elderly. Cherin Pace, RDH, MS, CCC-SLP Department of Dental Hygiene College of Health Related Professions. Course Objectives. The Participants will: Describe normal age-related changes for the various oral tissues.

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The Consequences of Oral Disease in the Elderly

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  1. The Consequences of Oral Disease in the Elderly Cherin Pace, RDH, MS, CCC-SLP Department of Dental Hygiene College of Health Related Professions

  2. Course Objectives • The Participants will: • Describe normal age-related changes for the various oral tissues. • Discuss the oral disease potential for the elderly to include caries, periodontal disease, and oral cancer. • List and describe the issues related to dentures. • Discuss the causes and effects of xerostomia in the elderly population, particularly in relationship to polypharmacy. • Identify relationship of oral disease to systemic diseases • cardiovascular disease, respiratory illness, diabetes.

  3. Oral Health of Senior Citizens • Less than 20% have dental insurance • Medicare dental coverage • Adult Medicaid dental coverage • Many have benefited from water fluoridation and “routine” care during their lifetime • ↓ Edentulism rate • More seniors with more teeth!

  4. Edentulism • 27% edentulism rate in the U.S. • Lowest in the world • Highest in West Virginia • Lowest in California • Reduced masticatory efficiency • 300 lbs/square inch with natural teeth • 50 lbs/square inch with dentures • Alveolar ridge absorption • 50% within two years of extractions • Speech function • Loss of vertical dimension

  5. Oral Manifestations of Aging • Lips • Oral mucosa • Tongue • Enamel • Cementum • Dentin • Pulp • Alveolar bone • Salivary glands • Hyperkeratosis • Dental caries • Root caries • Periodontal disease • Oral cancer • Issues related to dentures

  6. The Oral Cavity:Normal Age-Related Changes

  7. Tongue • Atrophic glossitis • “burning tongue” • smooth, shiny, and bald w/ atrophied papillae • iron deficiency or combination of deficiencies • Taste sensations • no reduction in number of taste buds • increased threshold for sweet and salty Sublingual varicosities

  8. Other Oral Tissues ORAL MUCOSA: • Decreased salivary secretion • secondary to disease or medications • Atrophic changes • thinner, less vascular tissues • loss of elasticity • appear smoother, shinier • Hyperkeratosis • chronic irritation • Candidiasis • Capillary fragility • petechiae • hematomas LIPS: • Tissue changes • dryness • loss of elasticity • thin vermillion border • Angular cheilitis • loss of vertical dimension • candidiasis or vitamin B deficiency

  9. Other Oral Tissues DENTIN: • Formation of secondary dentin • response to prior trauma • decreased pulp chamber • Decreased thickness • Yellowing ENAMEL: • Brittle, thin • reduced blood flow •  translucence> yellowing • Abrasion & Attrition

  10. Other Oral Tissues CEMENTUM: • Exposure due to attachment loss • cumulative of lifetime • Increased thickness • Diminished regeneration PULP: • Narrowing of chambers • Due to formation of 2ndary dentin • Fibrotic • Reduced blood supply • less cellular • Pulp stones

  11. Alveolar Bone • Decreased blood flow • Osteoporosis • > Bone quality that is less dense • Bone loss is not an inherent part of aging

  12. Oral Disease:Caries Tooth decay Cavities

  13. Dental Caries • Coronal caries • decreased incidence with age • Root caries • increased incidence • gum recession > exposure of root surfaces • Xerostomia • Physical dexterity

  14. Risk Factors for Caries in the Elderly • Dry mouth • Poor oral hygiene • Gingival recession • Cognitive or physical impairments • High number of bacteria • High carbohydrate diet • Partial dentures • Access to care

  15. Worst Case Scenario

  16. Consequences of Dental Infections • Extreme tooth pain • Bacteremia • Facial cellulitis • Brain abscess • Airway compromise

  17. Strategies to Reduce Risks • Powered or sonic toothbrush • More frequent recall appointments • Xylitol chewing gum • High-fluoride toothpastes • 5,000 ppm • Fluoride varnish • Dietary counseling

  18. Oral Disease:Periodontal DiseaseGum DiseasePyorrhea

  19. Periodontal Disease • Elderly at increased risk • Not a normal part of aging • Risk factors • Potential for osteoporosis • Decrease tissue vascularity • Increased risk for infection • Xerostomia (secondary) • Chronic disease and physical dexterity • altered immune response • medication side effects • plaque removal skills

  20. What is Periodontal Disease? • A gram-negative infection • Produces a variety of inflammatory responses • Inflammation triggers the immune response • Increase in inflammatory mediators • Prostaglandin E • Interleukin-1 • Tumor necrosis factor-alpha (TNF)

  21. Periodontal Disease • In addition to the inflammatory response, • Release of cytokines • Type of protein cell • produced by immune cells • act as mediators • > information / signals from one cell to another • to influence behavior of other cells

  22. Periodontal Disease • Bacterial infection • Destroys • attachment fibers • supporting bone that holds the teeth in the mouth • When attachment is destroyed • gum tissue separates from the tooth • pockets forms • fill with plaque • harbor bacteria

  23. Healthy Gingival Tissue • Characterized by healthy coral pink color • Firm attachment of tissue against the teeth

  24. Periodontal Disease Stages • Acute (gingivitis) • Short-term response • Few days to 3 weeks • Reversible • Subacute (periodontitis) • Mid-term response • 4-8 weeks • Chronic • Long-term response • months or years

  25. Signs & Symptoms • Gingiva • red, swollen, and inflamed • Interdental papilla • puffy and bleeds easily when probed • Generalized plaque accumulation • Patient may report bad odor &/or taste • Tooth mobility in more severe cases

  26. Severe Cases

  27. Diagnosis • Periodontal probing measures the sulcus depth around each tooth • Healthy areas measure 3mm or less without bleeding • Radiographs assess alveolar bone level

  28. Treatment • Mechanical removal of hard & soft deposits & pathogens • Scaling and root planing • Locally applied antimicrobials benefit pockets >5mm • Increase effectiveness of home care • Antimicrobial/anti-inflammatory toothpaste containing Triclosan • mouth rinses- CHX

  29. Oral Disease:Oral Cancer

  30. Oral Cancer • Increased incidence w/ age •  at age 40 •  again at age 60 • Gender • Male > female • Side effects of radiation therapy • Xerostomia • Oral ulcerations • Osteoradionecrosis • Mucositis, trismus, radiation caries

  31. Oral Cancer: The Numbers • 30,000 Americans diagnosed annually • 8,000 deaths per year • 1 person per hour, 24 hours per day • 50% live past 5 years • Higher death rate than: • cervical cancer, Hodgkin's disease, brain cancer, liver, testes, kidney, skin cancer (malignant melanoma)

  32. Risk Factors TOBACCO HUMAN PAPILLOMA VIRUS Increase in oral CA in nonsmokers / nondrinkers 27% oral CA no risk factors HPV > 20-30% of oral CA cases MALNUTRITION Diet low in fruits & vegetables • Smoking & Spit tobacco • 90% of all oral cancer pts • Risk ^ w/ amt used / duration of habit ALCOHOL • 75-80% • 6 times more likely than non-drinkers BOTH • 75% • men

  33. High Risk Areas for Oral Cancer • floor of mouth • lateral border of tongue • oropharynx • soft palate/throat • lower lip

  34. 95% of oral cancers White leukoplakia Red erythroplakia Red & white lesions erythroleukoplakia Squamous Cell Carcinoma

  35. Squamous Cell CarcinomaFloor of the Mouth

  36. Squamous Cell Carcinoma Lateral Border of the Tongue

  37. Squamous Cell Carcinoma Tip of the Tongue Oropharynx

  38. Squamous Cell Carcinoma Lower Lip > 30% of pts w/ cancers of the lip have outdoor jobs associated w/ prolonged exposure to the sun

  39. Snuff Keratosis

  40. Melanoma Kaposi's Sarcoma

  41. Erythroplakia • Surgical excision followed by biopsy for diagnosis • May need follow-up radiation and chemo • Close follow-up • 1mo, 3mo, 6mo, 12mo

  42. Oral Cancer Assessment and Treatment

  43. Issues Related to Dentures Be true to your teeth or they will be false to you!

  44. Issues Related to Dentures • Loss of vertical dimension • Angular cheilitis • Denture stomatitis • Inflammatory papillary hyperplasia • Epulisfissuratum

  45. Loss of Vertical Dimension Candidiasis TMJ implications; Appearance; Function

  46. Removable ProsthesisPapillary Hyperplasia

  47. DRUG IMPLICATIONS OF AGING • POLYPHARMACY • Multiple medications • both OTC & Rx • for multiple disease processes

  48. Salivary Gland Function • Minor salivary gland dysfunction • labial glands • No documented reduction from parotid or submandibular glands • Xerostomia is secondary to disease/medications • caries, dry lips, painful mucosa, dysphagia, taste acuity • Xerostomia is NOT a part of normal aging

  49. Medication-Induced Xerostomia • Anticholinergics • Antihistamines • Antidepressants • Antineoplastics • Antipsychotics • Diuretics • Antihypertensives • Bronchodilators • Amphetamines

  50. Gingival Hyperplasia • Drug induced • Phenytoin • Calcium channel blockers • Cyclosporin

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