ORAL DISEASES AND DISORDERS Suggestions for Lecturer -1-hour lecture -Use GRS slides alone or to supplement your own teaching materials. -Refer to GRS for further content. -Supplement your lecture with handouts. -See GRS7 question numbers 32, 164, 178, 182, 200 and 249 for case vignettes on oral diseases and disorders. Topic

OBJECTIVES Know and understand: Normal age-related changes of the teeth, gums, and salivary glands The significance of dental caries and periodontal disease, and how to help patients prevent them How to counsel patients about the care and use of dentures Proper management of dry mouth How to identify and initially address oral cancer and other problems of the oral mucosa Topic

TOPICS COVERED The Aging of the Teeth Dental Decay Diseases of the Periodontium Toothlessness Salivary Function in Aging Oral Lesions Chemosensory Perception Common Medical Considerations in Dental Treatment Topic

DYSFUNCTION AND DISEASE IN THE MOUTH Has an impact on overall health and social functioning Especially important for people who are frail or nutritionally at risk Findings prevalent in older patients: Decayed or missing teeth Periodontal disease Salivary hypofunction Not normal—patients should be urged to seek preventive and therapeutic care Topic

TOOTH AND PERIODONTAL ANATOMY Bullet points Topic

AGE-RELATED CHANGES IN ORAL TISSUES Tissue Affected Nature of Change Clinical Significance Tooth dentin Increased thickness Diminished pulp space Diminished permeability resulting from sclerosis of dentinal tubules Diminished sensitivity of dentin Diminished susceptibility to effects of bacterial metabolites Increased tooth brittleness Dental pulp Diminished volume Diminished reparative capacity Diminished sensitivity and alteration in nature of sensitivity Shift in proportion of nervous, vascular, and connective tissues Salivary glands Fatty replacement of acini Possibly less physiologic reserve Most age-related changes in teeth are subtle but become significant in the presence of environmental factors or disease. For a combination of reasons, the teeth of an older person are typically less sensitive or wholly insensitive to temperature changes and, importantly, to the sensations that commonly herald dental disease in younger adults. It is not uncommon to observe profound yet asymptomatic untreated dental disease in an older person’s mouth. Topic

DENTAL DECAY (CARIES) Bacterially derived demineralization, cavitation Can attack teeth throughout the lifespan Some types are more common in older people: Recurrent caries—decay at the interface of a dental restoration (eg, filling or crown) and tooth Root caries Both recurrent and root caries are generally asymptomatic—may become advanced before discovery Older people have more restored teeth (and usually the restorations are older and more extensive) and thus are more likely to have recurrent caries. The teeth of older people may feature more caries of the root surfaces than are typically observed in younger people because prior periodontal disease exposes the root surface, thereby predisposing it to demineralization and increased risk for caries. Topic

ADVANCED DENTAL DECAY May result in necrosis of the remaining pulp, usually leading to acute or chronic dental abscess Should be treated, even if not painful, because of high risk for serious metastatic infections Severe metastatic infections of dental and oral origin have been reported in virtually every organ system. In particular, α-hemolytic (viridans) streptococci of the oral cavity have long been implicated in close to one third of the cases of bacterial endocarditis reported annually in the United States, and bacteria associated with dental abscesses (eg, Staphylococcus aureus) have been cultured from the aspirates of infected hip arthroplasties. Topic

RISK FACTORS FOR DENTAL DECAY Poor oral hygiene—often due to impairment of visual acuity, manual dexterity, or upper-extremity flexibility; or diminished salivary flow Frequent ingestion of sticky foods with a high sucrose content (cake, candy, etc.) Infrequent dental visits Permanent or removable artificial teeth Limited lifetime exposure to fluoride The risk factors for dental caries are the same at any age, but many of the risk factors increase in prevalence as people age. White older Americans display a higher incidence of root caries than either black or Hispanic older Americans, but they are more likely to have received dental treatment for the lesions. Recurrent caries are also more common in white older Americans because of the greater likelihood that they have received prior dental treatment. Topic

PREVENTION OF DENTAL DECAY Daily brushing with fluoride toothpaste Daily flossing that includes the side of the teeth within the gingival sulcus Limitation of sugar intake Regular dental examinations, every 6–12 months Topic

TREATMENT OF DENTAL DECAY Topical high-potency fluoride for remineralization of incipient (non-cavitated) lesions Removal of demineralized tooth structure (“drilling”) Replacement of removed tooth structure with fillings or crowns When dental pulp is involved—root canal and reinforcement of the remaining tooth structure with a crown (“cap”) Topic

PERIODONTAL DISEASE (1 of 4) The periodontium consists of: The gingiva The alveolar bone The periodontal ligament—a collagenous sleeve between the tooth root and surrounding bone Periodontal disease occurs when microorganic colonies (plaque) form: On the teeth near the gingiva (causing gingivitis) and predisposing to plaque growth Between the gingiva and the root surface within the gingival sulcus (predisposing to periodontitis) Topic

PERIODONTAL DISEASE (2 of 4) Gingivitis—the inflammatory reaction to plaque is limited to the gingiva Rapidly reversible following removal of plaque Periodontitis—inflammatory process extends to the periodontal ligament and alveolar bone Irreversible; destroys hard and soft tissues of the periodontium Gingivitis is the most common form of periodontal disease. It develops more rapidly in healthy older adults than in younger ones, but in both groups the changes—including gingival edema and light bleeding on brushing—are rapidly reversible following removal of plaque. In most adults, periodontitis is a process marked by long periods of disease quiescence punctuated by bursts of localized destructive inflammation. The prevalence of active periodontitis is 20% to 40% of dentate adults (adults with teeth). By their 50s, more than 90% of dentate Americans show 2 mm or more of lost alveolar bone height, the primary marker of prior periodontal disease activity. In advanced cases of periodontitis, the decreased support around a tooth leads to its malposition, loosening, and eventual loss. Topic

PERIODONTAL DISEASE (3 of 4) Risk factors for periodontitis: Advancing age Smoking Poor oral hygiene Black and Hispanic Americans have a significantly higher prevalence of advanced periodontitis than do white Americans Periodontitis has been linked to the pathogenesis of diabetes, peripheral vascular disease, cerebrovascular disease, coronary artery disease and atherosclerosis, and nosocomial pneumonia Epidemiologic data support the concept that people who reach advanced age without significant periodontal bone loss will not likely experience a worsening of the disease in senescence. In contrast, adults who have experienced a more rapid rate of bone loss commonly will have lost teeth in their 40s and 50s. Periodontitis has been long reported to be worse in patients with poorly controlled diabetes mellitus. Investigations also support the contention that periodontitis, as an active infection, impairs diabetic control. Periodontal disease may be rapidly destructive in a patient whose immune system is impaired by disease or immunosuppression therapy. Epidemiologic data also correlate osteoporosis and tooth loss due to periodontitis. Periodontal disease and the pathogens responsible for it have been linked epidemiologically and immunologically with peripheral vascular disease, cerebrovascular disease, and pneumonia. Similar correlations have been reported for coronary heart disease, although one report disputes this. There is also epidemiologic association between gram-negative pneumonia, gram-negative periodontal pathogens, salivary hypofunction, and impaired swallowing function. Topic

PERIODONTAL DISEASE (4 of 4) Managing periodontal disease involves debriding the roots below the gingiva, which may require surgical access Topical antibiotics (chlorhexidine, oral rinse) and systemic antibiotics (minocycline, metronidazole, doxycycline) are increasingly used as adjuncts to other periodontal therapy Topic

TOOTHLESSNESS (EDENTULISM) In the 1960s more than 70% of Americans ≥75 were without teeth By the 1990s fewer than 40% of Americans ≥75 were without teeth Removal of one or more teeth in an older adult may be necessitated by various combinations of physiologic and behavioral factors. The leading cause is inability or unwillingness to access and pay for restorative dental treatment in the face of a symptomatic dental disease, usually stemming from dental caries. A second common cause is loosening of teeth as a consequence of periodontal disease, to the point that mastication becomes painful or ineffective, or both. The third common cause is removal of otherwise healthy teeth to facilitate the fabrication or function of a dental prosthesis. Not Toothless Toothless Topic

EDENTULISM Currently affects nearly 50% of Americans ≥85 When a person has lost all teeth and there are no prosthetic replacements: Facial appearance is dramatically changed Chewing ability is severely compromised Impact on nutritional intake in anecdotal cases but unestablished epidemiologically One longitudinal study employing diet diaries demonstrated a correlation between loss of teeth and increased carbohydrate intake, decreased protein intake, and diminished intake of selected micronutrients. Topic

<10% of older people have dental insurance REMOVABLE DENTURES Can aid in speech Restore facial contours Less predictable in restoring ability to chew Require periodic professional adjustment Not covered by Medicare Edentulous people with dentures are generally capable of eating a wider range of foods than edentulous people without dentures. Yet dentures restore, on average, only about 15% of the chewing ability of the natural dentition. The range of foods regularly eaten by denture wearers is significantly restricted in comparison with the dietary range of people with natural teeth. Denture wearers also have to chew more times before they swallow food, and they swallow their food in larger particles. Dentures often are a considerable source of discomfort, dysfunction, and embarrassment for older people. This is because the alveolar processes that originally held the natural teeth continually remodel and diminish in volume once the natural teeth are gone. For most patients, dentures require frequent professional adjustment and periodic replacement. Alveolar ridge resorption is most severe in the oldest patients who have had the longest time without natural teeth; this effect is more pronounced in those with osteoporosis. <10% of older people have dental insurance Topic

CARING FOR DENTURES Remove and clean after meals Soak in a commercial disinfectant several times each week Remove for several hours each day, or overnight See a dentist immediately in case of: Fractured or broken dentures Denture looseness or soreness Topic

SALIVARY FUNCTION IN AGING The major salivary glands undergo regressive histologic changes with aging Yet longitudinal studies have shown that with healthy aging, saliva production is essentially unchanged By extreme old age, healthy glands are more susceptible to factors that impede function, such as dehydration or drug-induced hypofunction Saliva is critical for protecting the tissues of the oral cavity and maintaining their function in speech, mastication, swallowing, and taste perception. Saliva buffers the intraoral pH, contains a wide spectrum of antimicrobial factors, remineralizes and lubricates the oral surfaces, and keeps the taste pores patent. Data from the Baltimore Longitudinal Study on Aging and the Veterans Affairs Dental Longitudinal Study have demonstrated that with healthy aging, flow from the parotid glands under both resting and stimulated conditions remains essentially unchanged. Both groups of investigators have reported that flow from the submandibular glands undergoes no change with age; other centers have reported a measurable but clinically minor decrease. It has been suggested that the major salivary glands show “organ reserve” in which the capacity of youthful glands exceeds ordinary demands, but that with age-related changes, functional reserves dwindle. Topic

CAUSES OF DRY MOUTH Drugs with anticholinergic effects, such as tricyclic antidepressants, opioids, anti-histamines, anti-arrhythmic agents, and anti-hypertensives Local diseases, such as salivary gland tumors and blocked ducts Systemic diseases that decrease salivary flow, such as Sjögren’s syndrome, depression, poorly controlled diabetes mellitus, and hypothyroidism Therapeutic irradiation of the head and neck Separate studies have found that 72% of institutionalized older patients received at least 1 (and some as many as 5) potentially xerostomic medications daily and that 55% of more than 4000 rural community-dwelling older people took at least 1 potentially xerostomic medication daily. Topic

MANAGEMENT OF DRY MOUTH Medications that may be decreasing salivary flow should be decreased or discontinued; or alternatives suggested OTC salivary substitutes and oral lubricants can provide transient relief Counsel patients on the high risk of oral disease: Limit sugar in their diet Optimize their daily oral hygiene Topic

ORAL CANCER Age is the primary risk factor for oral cancer Squamous cell carcinoma accounts for 96% of oral and oropharyngeal malignancies 5-year survival rate: 55% for white Americans, 34% for black Americans Oral cancer is strongly linked with the use of tobacco, especially cigarettes Alcohol use exacerbates the effects of tobacco Carcinoma of the lip, tongue, and floor of mouth represents more than 65% of all oropharyngeal cases. Lip cancer affects men 8 times more frequently than women; most other sites affect men at a ratio slightly below 2:1. Lip cancer is strongly correlated with pipe and cigar smoking. Topic

DETECTING ORAL CANCER Erythroplakia—red or mixed red/white lesions As many as 93% display cellular atypia Biopsy immediately Leukoplakia—white lesions Malignant or premalignant <10% of the time Monitor closely Biopsy if increasing in size or not gone in 14 days Older smokers should receive an annual oral evaluation by a qualified professional Early identification of oral cancer markedly improves outcome: 5-year survival without nodal involvement is 80% in white Americans and 69% in black Americans. Survival rates decline with nodal involvement (41% in white Americans and 30% in black Americans) and with distant metastases (18% and 12%, respectively). A thorough oral cancer screening, which can be completed in less than 2 minutes, consists of a head and neck nodal assessment followed by inspection of the oral cavity using gauze to retract the tongue and tongue blades to enhance visualization of the cheeks, lips, and vestibules. Topic

SQUAMOUS CELL CARCINOMA d b e Erythroplakia in a 72-year-old man with a history of cigar smoking and alcohol abuse. Lesion confirmed by biopsy to be invasive squamous cell carcinoma, poorly differentiated. f c g e a-right posterior maxillary alveolar ridge b-inner aspect of right cheek c-erythroplakia d-soft palate e-tongue retractor (dental mirror) f-tongue dorsum g-mandibular denture Topic

ORAL SQUAMOUS CELL CARCINOMA d c a c Leukoplakia in a 66-year-old man with a history of smoking. Lesion confirmed by biopsy to be carcinoma in situ. b a-right lip commissure b-tongue c-inner aspect of left cheek d-leukoplakia Topic

TREATMENT OF ORAL SQUAMOUS CELL CARCINOMA Localized disease is generally treated surgically Large, localized tumors may be managed with radioactive implants Extensive disease requires surgery followed by beam irradiation Radiation alone may shrink inoperable tumors Newer protocols combine surgery and chemotherapy with the goal of a cure Topic

CANDIDIASIS Presents as diffuse erythema, cracking at the corners of the mouth, curd-like white patches, or erythema in denture areas Can result in taste dysfunction, burning, itching, and pain Exclude any immunopathic cause for the disease Managed with topical or systemic antifungal agents and optimal oral and denture hygiene Older patients are particularly susceptible to candidiasis because of denture use, salivary hypofunction, the prevalence of diabetes mellitus, and the use of antibiotics for pulmonary and urologic diseases. Patients who use inhaled corticosteroids also are at higher risk and should be instructed to rinse out their mouth after using the inhaler. Topic

HERPES SIMPLEX Virus residing preferentially in trigeminal ganglion, periodically causing intraoral outbreaks Clusters of small, circular, red-rimmed, yellow, highly contagious blisters Outbreaks limited to hyperkeratotic areas of palate and to gingival and extraoral lips

EARLY LESIONS OF HERPES SIMPLEX, RIGHT PALATE

BURNING MOUTH SYNDROME Chronic oral-facial pain disorder, usually without other clinical signs Typically affects women ≥50, with a particularly high attack rate in Asian Americans and Native Americans Multiple causes have been suggested, including xerostomia, denture use, candidiasis, nutritional deficiencies, and psychiatric disorders Treatment is empirical and symptomatic Topic

HAIRY TONGUE Idiopathic disruption of desquamation of tongue filiform papillae results in elongation of papillae and appearance of “hairy tongue” Condition can serve as substrate for bacterial or fungal growth

BLACK HAIRY TONGUE

CHEMOSENSORY PERCEPTION: OLFACTORY FUNCTION (1 of 2) It is a common misperception that the number of taste buds diminishes with advanced age, based upon a mistranslation of an early 20th century anatomical study This erroneously reported finding has not been replicated in over 100 years, and the misinformation has been perpetuated without basis Topic

CHEMOSENSORY PERCEPTION: OLFACTORY FUNCTION (2 of 2) Olfactory (smell) function declines with age The decline affects older men to a greater extent than older women Impaired olfaction in older people has been anecdotally implicated as a risk factor for eating spoiled food or failing to notice gas leaks or domestic fires Several drugs have been implicated in smell dysfunction, as has Alzheimer’s disease, among other disorders common among older people. Topic

UPPER AERODIGESTIVE & RESPIRATORY CAUSES OF TASTE DYSFUNCTION Dental infection Periodontal disease Poor oral hygiene, including poor denture hygiene Sinusitis Tobacco smoking or use of nasal snuff Tumor of airway or sinus Upper respiratory infection (bacterial or viral) Topic

CHEMOSENSORY PERCEPTION: TASTE PERCEPTION The subjective perception of saltiness and sweetness shows blunting with advancing age This change potentially has clinical significance, possibly playing a role in a person’s tendency to oversalt foods or crave sweets Some drugs may have no primary effect on taste but cause diminished saliva flow and lead to impaired taste perception One’s sense of “taste” may actually be more accurately termed “flavor” —that is, the full range of sensations that accompany eating, including temperature, texture, sound, and smell in addition to the perception of sweet, salt, sour, and bitter. Flavor perception is prone to impairment in the older person because of changes in olfaction and oral stereognosis, salivary hypofunction, and the presence of dentures, which present physical and thermal barriers. Flavor enhancement strategies have been shown to have positive effects on both food preference and caloric intake among frail older patients. Topic

EXAMPLES OF DRUGS THAT INTERFERE WITH TASTE Acyclovir Diclofenac Nelfinavir Allopurinol Diltiazem Ofloxacin Amiloride Enalapril Nifedipine Amitriptyline Ethacrynic acid Pentamidine Ampicillin Fenoprofen Pentoxifylline Baclofen Gemfibrozil Phenytoin Buspirone Hydrochlorothiazide Procainamide Captopril Imipramine Propafenone Chlorpheniramine Labetalol Propranolol Desipramine Lomefloxacin Sulfamethoxazole Doxepin Mexiletine Sulindac Dexamethasone Nabumetone Tetracyclines SOURCE: Data from Schiffman SS, Zervakis J. Taste and smell perception in the elderly: effect of medications and disease. Adv Food Nutr Res. 2002;44:247–346. The source lists more than 250 agents reported to disturb the sense of taste. The agents listed on this slide and the next are those for which taste disturbance was objectively determined through threshold or intensity scaling or both, employing one or more standardized solutions. Topic

ORAL CAUSES OF TASTE DYSFUNCTION Burning mouth syndrome   Candidiasis Laceration Malignancy Salivary hypofunction Therapeutic irradiation of head Thermal or chemical burn Topic

OTHER CAUSES OF SMELL AND TASTE DYSFUNCTION Alzheimer’s disease, other neurodegenerative disorders Central nervous system tumor (taste only) Endocrinopathies (eg, diabetes, Cushing’s syndrome, adrenocortical insufficiency, hypothyroidism) Head trauma Nutritional deficiencies (vitamin B12, zinc) Psychiatric disorder Stroke Topic

OSTEONECROSIS OF THE JAW (ONJ) IV bisphosphonate (BP) treatment for malignancy (eg, myeloma, metastases of breast or prostate cancer) has been linked to ONJ Cases of ONJ following oral BP therapy (eg, for osteoporosis) are extremely rare Risk factors have not been definitively determined, but history of recent trauma (eg invasive dental surgery or other intraoral trauma) and a mandibular location of the trauma seem to be strongly linked to onset; total BP dose and duration since last dose are not Patients who are going to receive IV BP should complete needed dental care before BP is started Patients who have received IV BP must be educated to inform dental providers before undergoing dental care, to minimize likelihood of intraoral mandibular trauma during dental treatment See GRS7 Tables 58.4 and 58.5 for antibiotic prophylaxis Slide 41 Topic Slide 41

OTHER COMMON MEDICAL ISSUES IN DENTAL TREATMENT ⅓ of reported cases of infective endocarditis caused by organisms normally found in the mouth Prophylactic antibiotic coverage recommended only in specific high-risk situations For invasive dental treatment in a patient on an anti- coagulant regimen, no preoperative change in medication is indicated as long as INR < 3.5 and local measures are used to limit postop bleeding Remote risk of precipitating cardiac event in patients due to accidental intravascular injection of epinephrine should not in general be of concern See GRS7 Tables 58.4 and 58.5 for antibiotic prophylaxis Topic

SUMMARY (1 of 2) Teeth become less sensitive with age, and it is not uncommon to observe profound yet asymptomatic untreated dental disease in older people, which justifies a need for regular dental evaluation every 6–12 months Periodontitis caused by plaque formation within the gingival sulcus may lead to loss of alveolar bone height, decreased support around the tooth, malposition, loosening, and eventual loss of the tooth Topic

SUMMARY (2 of 2) Dentures usually aid in speech and restore diminished facial contours, but improvement in nutritional status due to enhanced chewing ability is unpredictable Oral cancer screening is critical to detection and treatment of early-stage oral cancer, translating into improved outcomes and better survival rates Topic

CASE 1 (1 of 3) A 72-year-old woman comes to the office because she has pain at the site of a mandibular tooth extraction performed 8 months earlier. She has a history of metastatic breast cancer and has been receiving intravenous bisphosphonate for the past 12 months. On examination, the extraction socket has not healed, and the gingival tissue is open, with bone protruding from the site. The area is erythematous, and some purulent drainage is apparent. Slide 45 Topic Slide 45

CASE 1 (2 of 3) Which of the following is the most likely diagnosis? Cancer metastatic to the mandible Osteomyelitis of the mandible Periodontitis Osteonecrosis of the jaw Incomplete tooth extraction with residual root Slide 46 Topic Slide 46

CASE 1 (3 of 3) Which of the following is the most likely diagnosis? Cancer metastatic to the mandible Osteomyelitis of the mandible Periodontitis Osteonecrosis of the jaw Incomplete tooth extraction with residual root ANSWER: D Bisphosphonate-related osteonecrosis of the jaw (ONJ) is a devastating complication of bisphosphonate therapy used for bone cancer lesions or osteoporosis. The American Association of Oral and Maxillofacial Surgeons defines this complication clinically as “exposed bone in the maxillofacial region that has persisted for more than 8 weeks in patients with current or previous [bisphosphonate] treatment, without a history of radiation therapy to the jaw.” It is most commonly seen after tooth extraction but can also develop with periodontal disease or trauma to the oral cavity, or spontaneously. Bisphosphonate-related ONJ can produce pain, swelling, infection, fistulae, and jaw fracture. Although the lesion has signs of secondary infection, the underlying pathophysiology is necrotic bone rather than infection. In cases of infected bisphosphonate-related ONJ, oral antibiotics and antibacterial mouth rinses are usually adequate to treat the infection, without biopsy. Breast cancer is unlikely to metastasize to the jaw. Normal healing of the extraction socket produces soft-tissue healing within 1 month and bony healing by 6 months. Although healing can be slower in older patients, especially if they have diabetes, an extraction socket should not remain open for >6 months, unless there is underlying pathology. Periodontitis is unlikely because it is present only when teeth are present, not in the area of a prior extraction. Incomplete tooth extraction with residual root is unlikely because this does not usually present with extruding bone from the socket. In addition, residual root can be easily excluded with a radiograph. Slide 47 Topic Slide 47

CASE 2 (1 of 3) An 80-year-old woman comes to the office because she recently has had difficulty eating and swallowing solid food. When she prepares to swallow, the food scrapes her cheeks and the roof of her mouth. Her history includes hypertension, diabetes mellitus, kidney stones, and major depressive disorder. Medications include hydrochlorothiazide, metformin, and fluoxetine. For the first time in many years, a recent dental examination revealed several cavities, which were located at the roots of the teeth. Topic

CASE 2 (2 of 3) Which of the following is the most likely explanation for these oral problems? Usual aging Salivary ductal stones Adverse effect of metformin Adverse effect of hydrochlorothiazide and fluoxetine Immune dysfunction Slide 49 Topic Slide 49

CASE 2 (3 of 3) Which of the following is the most likely explanation for these oral problems? Usual aging Salivary ductal stones Adverse effect of metformin Adverse effect of hydrochlorothiazide and fluoxetine Immune dysfunction ANSWER: D This patient’s difficulty eating and swallowing solid foods in the context of new dental cavities is most consistent with xerostomia, or decreased saliva. Signs and symptoms of xerostomia include oral dryness or burning, changes in tongue surface or taste, dysphasia, cheilosis, difficulty with speech, and development of root caries. Many conditions and treatments contribute to xerostomia, such as radiation or chemotherapy; psychologic, endocrine, and nutritional disorders; and adverse effect of medication (>200 commonly used medications can cause xerostomia). Antihypertensive medications (especially diuretics) and antidepressants (especially first-generation SSRIs) reduce saliva flow. Metformin is not known to decrease salivary flow. Immune diseases, such as Sjögren syndrome, and diabetes can increase cavities but are not likely to produce xerostomia. While older adults are likely to have a decreased amount of active glandular tissue, salivary flow does not decrease significantly with age. The causes of salivary stones (sialoliths) are largely unknown; theories include autoimmune and inflammatory causes. Kidney stones are unrelated to salivary stones. Salivary stones do not usually cause xerostomia; they usually affect only one gland (commonly the submandibular gland) on only one side, so saliva is still present in the other major and minor salivary glands. Treatment for patients with xerostomia includes scrupulous oral hygiene with a soft toothbrush, fluoride rinses, reduced alcohol consumption, frequent intake of water, saliva substitutes, and avoidance of highly acidic foods. Topic

CASE 3 (1 of 3) A 75-year-old man comes to the office because he has an ulcer on his tongue that is not painful except when he eats acidic or spicy foods. He does not remember when he first noticed it. His last dental examination was 2 years ago. He smoked 2 packs daily for 30 years but stopped smoking 20 years ago. He has hypertension controlled with medication. On examination, the patient’s non-healing ulceration is a 2  2 cm, indurated lesion on the left lateroventral border of the tongue next to a broken filling. Slide 51 Topic Slide 51

CASE 3 (2 of 3) Which of the following is the next best step? Refer patient to dentist to have filling restored. Refer for immediate biopsy of the lesion. Instruct patient to use an OTC local anesthetic gel to relieve the pain. Explain to patient that this is a canker sore that will resolve on its own in 7‒10 days. Recommend that the patient avoid acidic or spicy foods until the sore heals. Slide 52 Topic Slide 52

CASE 3 (3 of 3) Which of the following is the next best step? Refer patient to dentist to have filling restored. Refer for immediate biopsy of the lesion. Instruct patient to use an OTC local anesthetic gel to relieve the pain. Explain to patient that this is a canker sore that will resolve on its own in 7‒10 days. Recommend that the patient avoid acidic or spicy foods until the sore heals. ANSWER: B The clinical appearance of the ulcer—large and indurated, with rolled, firm edges—and its unknown duration make evaluation by a dentist imperative. Oral cancer claims approximately 8,000 lives in the United States each year. It is most common in people ≥40 years old, especially those with a history of smoking. Although head and neck cancer accounts for only 3% of all new cancer cases and 2% of all cancer deaths in the US annually, it is the fifth most common malignancy worldwide. Tobacco and alcohol are the primary etiologic agents. Squamous cell carcinoma, which accounts for 96% of all oral cancers, is usually preceded by dysplasia presenting as white epithelial lesions on the oral mucosa (leukoplakia), red and white lesions (erythroplakia), or a nonhealing ulcer. Early diagnosis and treatment markedly improve outcome and survival. Although the defective tooth filling could have precipitated the ulcer, the duration and clinical appearance of the ulcer indicate a precancerous or cancerous lesion. An OTC local anesthetic gel may provide temporary pain relief, but it does not treat precancerous, cancerous, or any other oral lesions. Canker sore is unlikely: a canker sore has a short duration and is a shallow ulcer covered by a yellowish white, removable, fibrinous membrane and surrounded by an erythematous halo. Avoiding spicy or acidic foods is not indicated; the patient needs immediate biopsy of the lesion. Slide 53 Topic Slide 53

Copyright © 2010 American Geriatrics Society ACKNOWLEDGMENTS Editor: Annette Medina-Walpole, MD GRS7 Chapter Author: Kenneth Shay, DDS, MS GRS7 Question Writer: Diana V. Messadi, DDS, MMSc, DMSc Kathryn A. Atchison, DDS, MPH Pharmacotherapy Editor: Judith L. Beizer, PharmD Medical Writers: Beverly A. Caley Faith Reidenbach Managing Editor: Andrea N. Sherman, MS Copyright © 2010 American Geriatrics Society Topic