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Medicine II: Geriatrics COPY > Oral and Dental in the Elderly > Flashcards

Oral and Dental in the Elderly Flashcards

1
Q

What do we do for the extraoral exam?

A

Palpate lymph nodes, palpate thyroid, look for asymmetry, look for skin/lip lesions

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2
Q

What to we do for the intraoral exam?

A 
Identify:
Swellings (diffuse vs. nodules)
Ulcers
White/red lesions
Tooth-related problems (decay, abscess, fracture)
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3
Q

What strucutres do we examine intraorally?

A 
Lips
Gingiva
Palate
FOM
Buccal mucosa
Tongue
Throat
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4
Q

What do we look for in a dental exam?

A

Fractured teeth
Dental Abscess
Decayed teeth

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5
Q

What are common oral and dental problems?

A

Infectious
Trauma-related
Medication-related
Mucosal abnormalities

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6
Q

What are common infectious diseases in the mouth?

A

Root caries, periodontal disease, candidiasis

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7
Q

What are common trauma related diseases in the mouth?

A

Epulis fissuratum, ulcers, hyperkeratosis

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8
Q

What are common medication related issues with the mouth?

A

Xerostomia, gingival hyperplasia, lichenoid reactions, ulcers, jaw necrosis

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9
Q

What are common mucosal abnormalities of the mouth?

A

Leukoplakia, erythroplakia, squamous cell carcinoma (SCCA)

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10
Q

What is the etiology of Root Carries?

A

Gingival recession & attachment loss
Bacteria
Diminished manual dexterity

Decreased saliva leads to an acidic environment and thus demineralization

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11
Q

What are the common bacteria that cause root carries?

A

Streptococcus mutans
Lactobacillus acidophilus
Actinomyces viscosus

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12
Q

How do root carries present?

A

Exposed root surfaces
Yellow, brown or black lesions on roots
Loss of tooth structure

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13
Q

What is the prevention management for root carries?

A

Fluoride!
Mouthwashes (ACT)
Varnish (applied at dental visits)
Excellent home care & regular dental visits

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14
Q

What is the restoration treatment for root carries?

A

Resin-modified glass ionomer
Bonds to tooth
Esthetic-tooth colored
Releases fluoride

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15
Q

What is the etiology of peridontal disease?

A

Poor oral hygiene
Disease-causing bacterial flora (mainly gram -)
Underlying systemic factors & immunosuppression

Progressive inflammation of soft tissues leads to loss of the bone and thus tooth loss

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16
Q

How does peridontal disease present?

A

“Long in the tooth”
Loss of gum tissue and bone support
Teeth become loose

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17
Q

What is the management of peridontal disease?

A

Professional deep cleaning (scaling and root planing)
Improved oral hygiene
Chlorhexidine rinse (Peridex)
Severe cases may require periodontal surgery or tooth extraction

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18
Q

What causes candidiasis?

A

Candida albicans

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19
Q

What are the types of candidiasis?

A

Pseudomembranous candidiasis (white)
Erythematous candidiasis (red)
Angular cheilitis
Denture stomatitis

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20
Q

What causes pseudomembranous candidiasis?

A

Abx, immune system dysfunction

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21
Q

What causes erythematous candidiasis?

A

Abx, xerostomia

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22
Q

What causes angular cheilitis?

A

decrease in vertical dimension

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23
Q

What causes denture stomatitis?

A

wearing dentures continuously

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24
Q

How do we treat candidiasis?

A

Antifungals:

  • Clotrimazole (Mycelex), 10 mg, dissolve 1 troche on tongue 5x/day for 2 weeks
  • Nystatin (tablet or rinse)
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25
Q

How do we treat angular cheilitis?

A

Athlete’s foot cream (Lotrimin, Tinactin)

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26
Q

How do we treat denture stomatitis?

A

Clean denture

Soak in OTC cleanser (Efferdent, Polygrip)

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27
Q

What is the etiology of Epulis Fissuratum?

A

Tumor-like hyperplasia of fibrous CT

Response to ill-fitting denture

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28
Q

What is the presentation of epulis fissuratum?

A

Firm, mucosal-colored folds in vestibule

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29
Q

What is the management of epulis fissuratum?

A

Surgical excision
Fix denture for proper fit
–Re-line or new denture

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30
Q

What is the etiology of traumatic ulcers?

A

Mechanical damage
Repeated trauma causes ulceration of surface
Accidental biting, sharp teeth, sharp foods, etc

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31
Q

How do traumatic ulcers present?

A

Most common on tongue, lips, & buccal mucosa

Removable, yellow membrane with a rolled white border and surrounding redness

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32
Q

What is the management of traumatic ulcers?

A
  • Remove irritating source
  • Palliative
  • Salt-water rinses
    Local anesthetic rinse (Dyclonine HCl )
    Hydroxypropyl cellulose films (Zylactin B)
  • Can resemble squamous cell carcinoma! (SCCA)
  • If present for longer than 2 weeks, advise referral to dentist/ENT/oral surgeon for biopsy
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33
Q

What is the etiology of traumatic hyperkeratosis?

A

Repeated trauma causes thickened layer of keratin

Biting/chewing habit, toothbrush trauma, tooth loss

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34
Q

How does traumatic hyperkeratosis present?

A

Thickened, white patch
Tongue, buccal mucosa, gingiva
Common on edentulous areas

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35
Q

What is the treatment for traumatic hyperkeratosis?

A

Biopsy often necessary to rule out pre-cancerous lesions (dysplasia)
Discontinue any habit
Smooth or extract sharp/broken teeth

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36
Q

What is xerostomia?

A

dry mouth

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37
Q

What are the causes of xerostomia?

A
  • Water/metabolite loss (Impaired fluid intake, Hemorrhage, V/d)
  • Iatrogenic (Meds, Rxt therapy to H&N)
  • Local factors (smoking, mouth breathing, decreased mastication)
  • Systemic diseases (Sjogren’s synd., DM)
38
Q

How does xerostomia presentation in the geriatric population?

A

25% of geriatric patients

Side effect of 2/3 of most commonly prescribed drugs

39
Q

What can develop from xerostomia?

A

Can lead to caries or candidiasis

40
Q

What might xerostomia cause? (symptoms)

A

Burning, discomfort, difficulty speaking, difficulty swallowing, decreased ability to taste

41
Q

What drug classes commonly cause xerostomia?

A 
Antianxiety
Antidepressant
Bronchodilators
Diuretics
Antihistamine
Antihypertensive
Antinflammatory
Muscle relaxants
Narcotic analgesics
Sedatives
42
Q

How does xerostomia present?

A

Tongue surface appears dry & may be fissured
No pooling of saliva in floor of mouth
Gloves may stick to oral mucosa
Saliva is thick and ropey

43
Q

What is the management for xerostomia?

A

Difficult & unsatisfactory
Artificial saliva
Stimulants (sugarless candy, medications)
Biotene (OTC rinse, toothpaste, gel)
Consider switching medications
Fluoride to prevent decay
Chlorhexidine (Peridex) to minimize plaque

44
Q

What is gingival hyperplasia?

A

Overgrowth of gingival tissue secondary to medication

45
Q

What are the common causes of gingival hyperplasia?

A 
Calcium channel blockers
 Amlodipine, nifedipine
Cyclosporine
Anticonvulsants
Phenytoin (Dilantin)
46
Q

What is the treatment for gingival hyperplasia?

A

Discontinue or switch medications if possible
Chlorhexidine
Frequent professional cleanings & excellent home care
Surgical excision

47
Q

What is the etiology of a lichenoid drug reaction?

A

Allergic reaction to medication

Often appear 6 months - 1 year after starting drug

48
Q

How does a lichenoid drug reaction present?

A

Clinically identical to true lichen planus
Ulcers with white radiating striae at periphery
Buccal mucosa, tongue, lips
May have superimposed candidiasis

49
Q

What are some drugs that can cause a lichenoid drug reaction?

A 
NSAIDS (Ibuprofen, naproxen, indomethacin)
Beta blockers (Propranolol)
Diuretics (Furosemide, HCTZ)
ACE Inhibitors (Lisinopril, captopril)
50
Q

What is the treatment for a lichenoid drug reaction?

A

Switch or discontinue medication if possible
Topical corticosteroids (Lidex, clobetasol)
–Steroid often ineffective if medication is continued
–Chlorhexidine to prevent candidiasis while on steroid
Mycelex or Nystatin if fungal infection present

51
Q

What is a fixed drug reaction?

A

Allergic reaction to medication that recurs at the same site

52
Q

What are common medications that cause a fixed drug reaction?

A

Barbiturates
Analgesics/antipyretics (Phenazone derivates, salicylates)
Antibiotics (dapsone, tetracycline, sulfa drugs)

53
Q

How does a fixed drug reaction present?

A

Similar appearance to traumatic ulcers

May affect any mucosal surface, often lip & tongue

54
Q

How does a fixed drug ulcer present? What do you do?

A

May clinically mimic malignancy

Biopsy often necessary to rule out carcinoma

55
Q

What is the treatment of a fixed drug reaction?

A
  • Switch or discontinue medication if possible
  • Topical steroids (Lidex, clobetasol)
    Often ineffective if medication is continued
  • Palliative treatment
    Salt-water rinses
    Local anesthetic rinse (Dyclonine HCl )
    Hydroxypropyl cellulose films (Zylactin B)
56
Q

What is a Osteochemonecrosis of the jaw?

A

Bisphosphonate related osteonecrosis of jaws (BRONJ)

57
Q

What is the etiology of an osteochemonecrosis of the jaw?

A

Osteoclast-inhibiting medications prevent normal bone remodeling

Results after trauma or tooth extraction

58
Q

What are common medications that cause a osteochemonecrosis of the jaw?

A 
IV bisphosponates (Zometa)
Oral bisphosphonates (Fosamax, Boniva, Reclast)
Monoclonal antibodies (denosamab/Prolia)
59
Q

What is the presentation of an osteochemonecrosis of the jaw?

A

Exposed, necrotic bone with surrounding inflammation

May be asymptomatic or painful

60
Q

What is the treatment for an osteochemonecrosis?

A 
Depends on stage, but generally:
Chlorhexidine rinse
Systemic antibiotics
Surgical debridement
Avoid elective dental surgery
Review indications for continued therapy
61
Q

What is leukoplakia?

A

“White patch” in the mouth
Strictly a clinical diagnosis
Must exclude other entities
Biopsy often necessary

62
Q

What are key factors about leukoplakia?

A 
Considered precancerous lesion
20% will be dysplastic or malignant
Most common oral pre-cancer
Most common over 40 years of age
Male predominant
63
Q

What is the etiology of leukoplakia?

A 
Exact cause unknown
Tobacco use
>80% of pts with leukoplakia are smokers
Heavier smokers have increased number & larger lesions
UV radiation
Lesions on lower lip
64
Q

How does leukoplakia present?

A

White appearance results from thickened surface keratin
90% with dysplasia or cancer found on:
Tongue (ventral/lateral), lip vermillion, floor of mouth

Defined white patch, Slightly raised and Fissured surface in a High risk location

65
Q

What are the progressive clinical changes of leukoplakia?

A

Thin plaques then thick, fissured raised lesions

May develop red patches=erythroleukoplakia

66
Q

Where are you most likely to find leukoplakia?

A

Most common on lip vermillion, buccal mucosa, gingiva

67
Q

What is the treatment of leukoplakia?

A

Biopsy, then definitive diagnosis directs treatment
Moderate dysplasia or worse mandates complete removal
Recurrence likely, especially for thick lesions
–Long-term follow-up is required
5% progress to SCCA

68
Q

What is erythroplakia?

A

“Red patch”, another strictly clinical diagnosis

Almost all are dysplasia or carcinoma

69
Q

What is the etiology of erythroplakia?

A

Exact cause unknown

Presumed to be the same as those for oral SCCA

70
Q

Who is more likely to develop erythroplakia?

A

Disease of middle-aged or older adults

Men & women affected equally

71
Q

What is the presentation of erythroplakia?

A

Well-demarcated, asymptomatic, erythematous plaque with soft texture
May have nearby leukoplakia

72
Q

Where are the most common sites of erythroplakia?

A

Most common sites:
Floor of mouth
Tongue (ventral/lateral)
Soft palate

73
Q

What is the treatment of erythroplakia?

A

Biopsy is mandatory!
Moderate dysplasia or worse should be completely removed
Recurrence is common & long-term follow-up is necessary

74
Q

What is a rule of thumb in regards to dental diseases/conditions and their regression?

A

If it doesn’t regress within two weeks, refer to dentist/oral surgeon/ENT for biopsy

75
Q

In the mouth, what should you be suspicious of and where?

A

Be suspicious of red or white lesions in the following areas:
Ventral & lateral tongue
Floor of mouth
Soft palate

76
Q

What is the prevelance of oral squamous cell carcinoma?

A

Oral SCCA make up 3% of all cancers in US
8th most common in males, 15th in females
95% of oral malignancies are SCCA

77
Q

What is the etiology of oral SCC?

A 
Multifactorial
Tobacco & alcohol
Human papilloma viruses (HPV)
Radiation, immunosuppression
Heredity is NOT a cause
78
Q

How does oral SCC present?

A

Most are preceded by a precancerous lesion
Erythroplakia or leukoplakia
Pts are usually older men
Minimally painful during early stages!!

79
Q

Where is oral SCC most likely to develop?

A

Lateral/ventral tongue
Floor of mouth
Soft palate

80
Q

What is the relationship between HPV and SCCA?

A

HPV implicated in up to 90% of oropharyngeal SCCA
Responsible for almost all oral SCCA in non-smokers & non-drinkers
Head & neck and throat cancer has increased 225% from 1988 to 2004:
Smoking-related SCCA has decreased 50%
Of all HPV-driven SCCA, 60-64 year olds comprise 11.5%
Responds better to treatment than conventional SCCA

81
Q

What type of HPV is most likely the cause of problems in the mouth?

A

HPV-16 most likely culprit in oral cavity

82
Q

What is the management of oral SCC?

A 
Wedge resection if on lower lip
Clinical stage guides intraoral SCCA treatment
--Wide excision
--Radiation
--Chemotherapy
83
Q

What are the 5 year survival rates of those with oral SCC?

A

stage 1. 70%, 85%
stage 2. 50%, 75%
stage 3. 40%, 60%
stage 4. 25%, 50%

in oral cavity, and on lip

84
Q

What are medical concerns with oral diseases?

A

Patients with complex medical history often require physician clearance prior to dental treatment

85
Q

What conditions may affect dental treatment?

A 
Cardiovascular disease
--MI: no elective tx for 6 months after MI
--Severe HTN: no tx until controlled 
--Take BP medication prior to dental tx
Anticoagulant therapy
--INR less than 3.0
86
Q

What are additional conditions that may affect dental treatment?

A

Syncope
–Most common emergency in dental office
–May result from orthostatic hypotension or medications
Diabetes
–Should be well controlled
–Pts should eat & take insulin prior to dental tx
–Do NOT operate if blood glucose > 250 mg/dL
COPD
–May not tolerate supine position

87
Q

What do we have to be cautious of in geriatric patients when giving them oral care?

A

Local injections
Lidocaine/xylocaine 2% with 1:100,000 epinephrine
Can cause cardiac abnormalities if injected intraarterially
Many older pts are sensitive to epi & may have palpitations
Toxicity
CNS symptoms, cardiac symptoms at high doses
Allergic reactions
Latex
Other dental materials

88
Q

What are the antibiotic prophylaxis guidlines for dental work?

A

Necessary for 2 types of patients:
–Heart conditions with increased risk for infective endocarditis
Patients with a total joint replacement
–At risk for hematogenous infection
One hour before “any dental procedure that involves manipulation of the gingival or periapical region of teeth or perforation of the oral mucosa”
–If pt forgets, can take up to 2 hours after

89
Q

What patients need antibiotic prophylaxis?

A

Heart conditions:
–Artificial valves
–Hx of infective endocarditis
–Cardiac transplant that develops a heart valve problem
Congenital heart conditions:
–Cyanotic congenital heart disease
–A congenital defect repaired with prosthetic material for 6 months after procedure
–Repaired congenital defect with residual defect

90
Q

What patients do not need antibiotic prophylaxis?

A 
Mitral valve prolapse 
Rheumatic heart disease 
Bicuspid valve disease 
Calcified aortic stenosis 
Congenital heart conditions:
--Ventricular septal defect
--Atrial septal defect 
--Hypertrophic cardiomyopathy
91
Q

What is the usual agent used in antibiotic prophylaxis with oral care?

A

amoxicillin

Medicine II: Geriatrics COPY (10 decks)

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