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 Course Objectives The Participants will: 1.Describe normal age-related changes for the various oral tissues. 2.Discuss the oral disease potential for the elderly to include caries, periodontal disease, and oral cancer. 3.List and describe the issues related to dentures. 4.Discuss the causes and effects of xerostomia in the elderly population, particularly in relationship to polypharmacy. 5.Identify relationship of oral disease to systemic diseases 1.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 l 27% edentulism rate in the U.S. n Lowest in the world n Highest in West Virginia n Lowest in California l Reduced masticatory efficiency n 300 lbs/square inch with natural teeth n 50 lbs/square inch with dentures l Alveolar ridge absorption n 50% within two years of extractions l Speech function l Loss of vertical dimension

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

6. The Oral Cavity: Normal Age-Related Changes

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

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

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

10. Other Oral Tissues CEMENTUM: l Exposure due to attachment loss n cumulative of lifetime l Increased thickness l Diminished r egeneration 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 l Coronal caries n decreased incidence with age l Root caries n increased incidence n gum recession > exposure of root surfaces Xerostomia Physical dexterity

14. Risk Factors for Caries in the Elderly n Dry mouth n Poor oral hygiene n Gingival recession n Cognitive or physical impairments n High number of bacteria n High carbohydrate diet n Partial dentures n 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 n Powered or sonic toothbrush n More frequent recall appointments n Xylitol chewing gum n High-fluoride toothpastes –5,000 ppm n Fluoride varnish n Dietary counseling

18. Oral Disease: Periodontal Disease Gum Disease Pyorrhea

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? l A gram-negative infection l Produces a variety of inflammatory responses l Inflammation triggers the immune response l Increase in inflammatory mediators n Prostaglandin E n Interleukin-1 n Tumor necrosis factor-alpha (TNF)

21. Periodontal Disease l In addition to the inflammatory response, n Release of cytokines Type of protein cell l produced by immune cells l act as mediators n > information / signals from one cell to another n 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 l Characterized by healthy coral pink color l Firm attachment of tissue against the teeth

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

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

26. Severe Cases

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

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

29. Oral Disease: Oral Cancer

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

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

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

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

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

35. Squamous Cell Carcinoma Floor 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 Erythroplakia l Surgical excision followed by biopsy for diagnosis l May need follow-up radiation and chemo l Close follow-up n 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 l Loss of vertical dimension l Angular cheilitis l Denture stomatitis l Inflammatory papillary hyperplasia l Epulis fissuratum

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

46. Removable Prosthesis Papillary Hyperplasia

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

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

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

50. Gingival Hyperplasia l Drug induced n Phenytoin n Calcium channel blockers n Cyclosporin

51. The Oral-Systemic Link: Diabetes Cardiovascular Disease Respiratory Illness

52. Porphyromonas gingivalis l Reported to be involved in the development of systemic diseases n due to systemic inflammation with increased circulating cytokines and mediators direct infection cross-reactivity/molecular mimicry between bacterial antigens and self- antigens Inaba, H. and Amano, A. 2010

53. Diabetes l Oral complications (generally limited to Type I) n Exacerbation of periodontal disease Periodontal disease more frequent Progression of periodontal disease more rapid Healing following surgery may be delayed Increased likelihood of infection n Candidiasis fungal infections more likely n Xerostomia issues Possibly due to disturbances in glycemic control

54. Cardiovascular Disease l A recent editors’ consensus regarding “Periodontitis and Atherosclerotic CVD” presented in the American Journal of Cardiology and Journal of Periodontology noted a significant relationship between periodontitis and atherosclerotic CVD. Inaba, H. and Amano, A. 2010

55. Periodontal Dz & Cardiovascular Dz From the Oral Cavity: n Macrophages, Neutrophils, Toxins, anaerobic bacteria in plaque l > Circulating inflammatory mediators n fatty acids, interleukin 1, tumor necrosis factor alpha l > Acute phase proteins n CRP, SAA, IL6, TNF alpha To the Heart: l > Heart and blood vessels, endothelial injury, lipid deposition, monocytemigration, smooth muscle proliferation l > Atherosclerosis, Cardiovascular disease, Stroke American Dental Association

56. Respiratory Illness Systematic Review Findings good evidence that improved oral hygiene and frequent professional oral healthcare reduces the progression or occurrence of respiratory diseases in high-risk elderly adults relative risk reduction of 34–83% Azarpazhooh & Leake

57. Aspiration Pneumonia l “… providing mechanical oral hygiene may prevent ~1 in 10 deaths from pneumonia in dependent elderly people and show similar pneumonia prevention effect.” l 15 publications (5 were RCT) n All revealed positive preventive effects of oral care on pneumonia or respiratory tract infection in nursing home residents. Sjogren et al

58. Variants of Normal

59. In Summary… Look in the Mouth l Be observant & ask questions n Last dental visit? What was done? n How long has this lesion been present? l Tobacco use? n Cigarettes, smokeless, cigars, pipes l Prosthetic appliances (dentures/partials) n Old, ill-fitting?

60. REFERENCES l American Dental Association Website. l Azarpazhooh, A., & Leake, J.L., (2006). J of Periodontology77:1465-482. l Cotti, E., Dessì, C., Piras, A., Mercuro, G. (2011). International Journal of Cardiology148: 4–10. l Inaba, H. and Amano, A. (2010). J Pharmacol Sci 113 :103 – 109. l Pace, C. and McCullough, G. (2010). Dysphagia 25:307–322. l Sjogren, P., et al. (2008). J American Geriatric Society 56: 2124-30.