Oral Disease in the Geriatric Patient: the Physician's Role

REVIEW I CME CREDIT^

Oral disease in the geriatric patient: the physician's role

MARSHA A. PYLE, DDS, AND GEZA T. TEREZHALMY, DDS, MA

HYSICIANS HAVE a In the elderly, oral health has a profound impact unique opportunity to on general well-being. The ability to quickly identify poten- detect significantly dete- tially harmful oral health problems is valuable to the physi- Priorated dentition and cian, who generally will see an older patient more often than other important oral abnormali- the dentist will. ties, because older patients are more likely to visit their physicians toa'fftMfcg Many medications and conditions can contribute than their dentists during a given to xerostomia and, therefore, to the development of dental period.1 caries and destruction of the teeth. Periodontal disease can The prevalence of oral disease also lead to increased susceptibility to caries and loss of teeth remains highest in the geriatric but is preventable through regular dental care. Bacteremia population (although the percent- originating in oral foci can cause serious conditions such as age of edentulous people over age endocarditis, infections of prosthetic joints, and contamina- 65 has improved from 60% in 1957 tion of vascular-access devices, especially in immunocom- to 42% in 1985).2,3 While oral dis- promised patients. To reduce their risk of bacteremia, eases seldom seriously impair neutropenic patients should receive broad-spectrum antibiot- health or threaten life, they worsen ics before undergoing dental procedures. Oral cancer is eas- the quality of life.4 Poor dentition ily treated if detected early. Patients undergoing cancer and oral functional impairment chemotherapy have special problems, as chemotherapeutic may hamper one's ability to live agents are highly toxic to the oral mucosa. without pain or discomfort, ingest and enjoy food, engage in satisfying INDEX TERMS: GERIATRIC DENTISTRY; ORAL HEALTH; AGED CLEVE CLIN ] MED 1995; 62:218-226 interpersonal relationships, maintain a favorable self-image, and be reasonably content with one's personal appearance. From the Department of Oral Diagnosis and Radiology, Case Western Re- serve University School of Dentistry, Cleveland, Ohio (M.A.P.), and the An approach to oral health in Department of Dentistry, The Cleveland Clinic Foundation (G.T.T.). geriatric patients should emphasize Address reprint requests to M.A.R, Department of Oral Diagnosis and enhancing function and the quality Radiology, Case Western Reserve University School of Dentistry, 2123 of life. Dolan5,6 has proposed that Abington Drive, Cleveland, OH 44106. oral health is characterized by "a comfortable and functional dentition that allows individuals to con- tinue in their desired social role"6;

218 CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 62 • NUMBER 4 Downloaded from www.ccjm.org on September 23, 2021. For personal use only. All other uses require permission. ORAL HEALTH • PYLE AND TEREZHALMY

physicians share a similar goal in regard to the gen- TABLE 1 eral health of the patient. HOW SALIVA INFLUENCES ORAL HEALTH* Simple guides to oral health assessment offer a systematic approach that may be useful in medical Lubricates practice.7,8 These guides can help physicians identify Protects mucous membrane gross oral abnormalities for which they would refer a Promotes wound healing patient to an appropriate dental professional for fol- Maintains ecologic balance low-up. Promptly identifying and treating signifi- Debrides cant diseases such as oral cancer can spare the pa- Impairs bacterial adherence, activity tient much pain and expense and result in lower Maintains oral pH overall medical costs. Maintains tooth integrity "Adapted from Mandel, reference 11 COMMON ORAL PROBLEMS IN THE ELDERLY

Edentulism undercuts and hydrostatic pressure to retain pros- Thanks to advances in research, public health thetic appliances. (including education and water fluoridation), and Additionally, mandibular resorption is often se- preventive care, great progress has been made in the vere enough to cause dentures to impinge upon the last 30 years in preserving the natural dentition. mental nerves, making mastication painful. This According to the National Institute of Dental Re- resorption has been shown to influence the type search, people over age 65 have an average of 17 and consistency of food selected by denture remaining natural teeth.5 Still, the current eden- wearers.9,10 tulism rate of 42% in the elderly emphasizes the Dentures in themselves have limitations. On the continuing need for preventive care. average, a dental prosthesis is only 25% as efficient As more older people retain their teeth, more of as the natural teeth and may have a functional life them are at risk of dental disease. Patients with span of only 5 to 7 years. cognitive decline and functional disabilities and who take many medications find oral health difficult Salivary function and xerostomia to maintain. These factors compound the problem Saliva plays an important role in maintaining oral of providing definitive dental treatment in medi- health (Table 1).11,12 It lubricates oral tissues and con- cally compromised patients. tains important enzymes and buffers that protect Preserving the natural dentition is crucial because against the initiation and progression of decay. the presence of natural teeth preserves the alveolar Saliva may also play an important role in pre- bone of the maxilla and mandible. Once teeth are venting gram-negative bacteria from colonizing the extracted, whether because of periodontal disease, oropharynx, from where they may be aspirated and caries, or trauma, physiologic processes begin that cause pneumonia.13 Colonization by gram-negative resorb the alveolar bone on a slow, continual basis for bacteria is more frequent in patients with severe the remainder of one's life. The bone of the maxilla illness; however, its basis is not fully understood. and mandible is sensitive to the pressures that natu- Decreased salivary flow has been suggested; salivary ral teeth provide during mastication. Without natu- proteins such as lactoferrin, lysozyme, and secretory ral teeth, these functional pressures are lost and the immunoglobulin A may prevent gram-negative bac- physiologic process of resorption begins. The greatest terial colonization by inhibiting bacterial adher- amount of bone loss occurs in the first 18 months ence.14 The relationships among salivary flow, sali- after extraction; thereafter, loss progresses at a rate of vary components, and gram-negative bacterial approximately 0.5 mm per year. colonization have not yet been fully researched. For many people age 65 and over who lost their The subjective feeling of oral dryness is common. teeth in young adulthood, edentulism has resulted Although salivary-gland function was once thought in severely resorbed mandibles or maxillae or both. to decline as a normal effect of aging, both the vol- Resorption is usually most troublesome in the man- ume and composition of saliva actually remain stable dible, where the resorption pattern leaves the bone despite documented changes in gland morphology flattened. This may impede the use of soft-tissue with age.15 Xerostomia is now attributed to local or

JULY • AUGUST 1995 CLEVELAND CLINIC JOURNAL OF MEDICINE 219 Downloaded from www.ccjm.org on September 23, 2021. For personal use only. All other uses require permission. ORAL HEALTH • PYLE AND TEREZHALMY

Treatment. Regardless of the cause of xerostomia, TABLE 2 MAJOR DRUG CLASSES treatment options remain limited to increasing sali- THAT MAY CAUSE XEROSTOMIA* vary flow when functioning glandular tissue remains Anticholinergics or to providing exogenous moisture when salivary Antidepressants flow cannot be increased. Antihistamines Patients who have some functioning of the glands Antihypertensives can stimulate salivary flow by chewing sugar-free Antiparkinsonians gum or noncitrus candy. Gustatory stimulation by Antipsychotics tart substances will also enhance salivary flow. How- Diuretics ever, acidic citrus extracts can cause demineraliza- Gastrointestinal tion of the tooth structure, predisposing the teeth to Sedative-hypnotics caries. Currently, researchers are studying the effects of pilocarpine as an agent to stimulate flow in pa- "Adapted from Baker et al, reference 23, and Mazer, reference 24 tients with residual salivary-gland function. For patients with no salivary-gland function, symptomatic treatment with artificial saliva and systemic disease, to the sequelae of radiation therapy water-based jellies can temporarily alleviate the dry to the head and neck, or to medications.16,17 feeling. Radiation therapy to the head and neck often Modification of drug regimens may alleviate causes irreversible salivary-gland changes as a side medication-induced xerostomia. Eliminating the effect. The rather rapid onset of dry mouth is caused drug, reducing the dose, altering the dosing sched- by the initial effects of ionizing radiation on the ule, or prescribing another drug within the same blood vessels and nerves of the glands. Later, exten- class as the implicated drug may be appropriate al- sive destruction of the parenchyma, especially the ternatives in certain patients. acini, may be seen. If residual functioning glandular All patients with dry mouth should be encour- tissue remains, decreased salivary flow may be evi- aged to seek regular dental care. A structured pro- dent for up to 6 months after irradiation. gram that includes periodic prophylaxis and daily The most common systemic condition that con- topical application of a 1.1% neutral fluoride gel in tributes to dry mouth is the chronic, multisystem, a custom-made tray is recommended to prevent car- autoimmune disorder, Sjogren's syndrome.18-20 In ies from starting or progressing. In some patients, this disorder, lymphocytes infiltrate the salivary 0.12% chlorhexidine gluconate rinses (Peridex, glands in a periductal pattern. The infiltrate is easily Procter & Gamble) can be an effective adjunct to documented by biopsy of the minor salivary glands daily oral care. This rinse, which has long-lasting of the lip. beneficial effects, is effective in treating gingivitis The most common cause of xerostomia, however, that arises from bacterial deposits in plaque. is medication.12,17 More than 400 medications have been implicated.21 Clinical studies have shown that Caries the elderly are more likely to be taking drugs, and Because the elderly are now retaining more of that the number of drugs taken increases with ad- their natural teeth, more teeth will be susceptible to vancing age.22 dental disease. Dental caries remain destructive in Specific classes of drugs cause xerostomia as a side older groups and are one of most common causes of effect. These drugs may either alter the physiologic tooth loss in adults. response to salivary secretion or contribute to the One type of caries frequently seen in the elderly is subjective feeling of dryness in patients without unique to this age group and occurs on root surfaces documented decreases in flow rate. The most com- exposed to the oral environment.25 Root exposure mon classes of drugs known to promote dry mouth (recession) occurs physiologically with age and also are listed in Table 2.23,24 as a consequence of periodontal disease. Loss of Without the protection saliva provides, the bacte- gingiva or bone surrounding the teeth, or both, ria in plaque are more adherent to the teeth. Hence, leaves the root areas susceptible to bacterial attack. the most important consequence of dry mouth is the This area of the tooth is composed of a softer mate- rapid destruction of the teeth due to caries. rial than the enamel covering the crown, and be-

220 CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 62 • NUMBER 4 Downloaded from www.ccjm.org on September 23, 2021. For personal use only. All other uses require permission. ORAL HEALTH • PYLE AND TEREZHALMY

cause it is softer, when caries occur there they pro- deposits (periodontal disease); xerostomia caused gress rapidly. by medications, radiation therapy, or systemic or The bacteria that cause root-surface caries are the local disease; and factors contributing to putrefac- same as those that cause coronal caries. Putative risk tion of tissues, such as major aphthae, tumors, or indicators for root-surface caries include older age, infection.30 Systemic conditions, such as diabetic certain microorganisms, coronal caries, and loss of ketoacidosis, hepatic failure, uremia, or upper respi- periodontal attachment.26 A recent report also im- ratory tract disease, can also contribute to unpleas- plicated frequent intake of simple sugars, high lacto- ant mouth odor. bacilli counts, and low salivary buffering.27 Treatment. Impeccable oral hygiene and eradica- Treatment. The strategies for preventing caries in tion of dental disease are essential to prevent offend the elderly parallel the preventive techniques for sive mouth odors. Brushing and flossing the teeth people with xerostomia. Routine measures include daily to eliminate bacteria-laden plaque and brush- dental checkups and adjunctive therapies such as ing the tongue (which can be a trap for bacteria, 1.1% neutral fluoride gel in a custom-made tray and food particles, and exfoliating epithelial cells) will chlorhexidine gluconate rinse. Control of dietary help assure more pleasant breath. Oral hygiene regi- and microbial factors may also decrease the inci- mens paralleling those used for patients with xeros- dence of root-surface caries.27 tomia are appropriate preventive measures to decrease plaque and prevent incipient caries. Periodontal disease Periodontal disease, like caries, has bacteria as its AND SYSTEMIC CONDITIONS primary cause. When specific bacteria indigenous to the oral cavity remain within the gingival crev- ice around each tooth for longer than 24 hours, Bacteremia they can initiate an inflammatory response that can Infections in the mouth and teeth have been progress to destruction of the alveolar-bone and implicated in causing bacteremia in patients who soft-tissue attachments around each tooth, result- have specific cardiac conditions, prosthetic joints^ ing in the loosening of the tooth and, eventually, renal disease, neutropenia, and diabetes, or who tooth loss. have undergone splenectomy. The management of Although the elderly show the greatest degree of these patients is a multidisciplinary responsibility» periodontal destruction, the disease is thought to The objectives of dental treatment are to ( 1 ) elimi1 result from cumulative insults over a lifetime rather nate or control oral and odontogenic disease, whicH than from aging itself.28 A recent review of could present a risk to patients susceptible to infec- epidemiologic studies summarized the risk indicators tion; (2) identify and reduce drug-related oral and for periodontal disease: people at risk are older, use odontogenic complications; and (3) initiate and tobacco, use dental services infrequently, have a his- maintain a program of patient education. tory of periodontal disease, have plaque or calculus To reduce the risk of morbidity and mortality, deposits, or are heavily infected with specific mi- patients should have a comprehensive clinical and crobes.29 Behaviors and infections can therefore in- radiographic oral examination before undergoing fluence disease status, regardless of age. cardiovascular surgery, organ transplantation, im- munosuppression, or total joint replacement; after Halitosis undergoing splenectomy; or after being found to Bad breath can be a significant problem in peo- have diabetes. Emphasis is placed on identifying ple susceptible to predisposing conditions. This infected or nonrestorable teeth, advanced periodon- problem can be intensified in dependent people tal disease, and other foci of oral or odontogenic who require caregivers to perform daily oral hy- infections. Emergent problems must be eliminated giene procedures. Bad breath odors usually arise aggressively. from a combination of factors, including an alka- Elderly patients who have undergone cardiovascu- line pH and the presence of sulfur-containing com- lar surgery, organ transplantation, or splenectomy or pounds from gram-negative bacterial metabolism. are diabetic or neutropenic need regular evaluation Predisposing factors for halitosis include poor oral to assess compliance with preventive measures and hygiene with accumulation of plaque and calculus to monitor drug-induced complications that can

JULY • AUGUST 1995 CLEVELAND CLINIC JOURNAL OF MEDICINE 221 Downloaded from www.ccjm.org on September 23, 2021. For personal use only. All other uses require permission. ORAL HEALTH • PYLE AND TEREZHALMY

TABLE 3 TABLE 4 INDICATIONS FOR ENDOCARDITIS PROPHYLAXIS* ANTIBIOTIC PROPHYLACTIC REGIMENS*

Most congenital cardiac malformations Standard regimen: Hypertrophic cardiomyopathy Amoxicillin 3.0 g 1 hour before procedure, 1.5 g 6 hours after initial dose Mitral valve prolapse with regurgitation For patients allergic to amoxicillin or penicillin: Previous bacterial endocarditis Erythromycin ethylsuccinate 800 mg 2 hours before Prosthetic cardiac valves procedure, 400 mg 6 hours later; or erythromycin stearate 1.0 g 2 hours before procedure, Rheumatic valvular dysfunction 0.5 g 6 hours later 'Adapted from Dajani et al, reference 33 Clindamycin 300 mg by mouth 1 hour before procedure, 150 mg 6 hours after initial dose

Adapted from Dajani et al, reference 33 contribute to new sources of oral or odontogenic problems, including infections. Finally, patients and their families should be fully informed about the bacteremia is of minor significance, 93% recom- importance of oral and dental health, with particular mend antibiotic prophylaxis before any dental pro- emphasis on its relationship to a particular disease. cedure likely to cause bacteremia.37 Because no for- mal recommendations exist for prophylactic Cardiac disease regimens in these patients, American Heart Asso- Transient oral or odontogenic bacteremias may ciation guidelines are usually followed unless the seed previously damaged cardiac endothelium, re- orthopedic physician prefers a specific antimicro- sulting in valvular vegetation, congestive heart fail- bial agent. ure, myocardial infarction, abscesses, and conduc- tion abnormalities. Infective endocarditis may result Splenectomy from oral streptococci, staphylococci, enterococci, Compared with people who have a spleen, as- Candida albicans, and other microorganisms.31,32 plenic patients are at 40 times the risk of serious Therefore, any patient susceptible to infective en- infection and 17 times the risk of fatal sepsis.38 Infec- docarditis who undergoes dental treatment likely to tion is most likely within the first 12 months after cause gingival or mucosal bleeding should be given splenectomy, but overwhelming infections have antibiotics prophylactically, and emergent dental been reported many years later.39 Microorganisms problems must be treated vigorously. The current implicated include streptococci, staphylococci, recommendations of the American Heart Associa- gram-negative bacilli, and other microorganisms tion for prophylaxis against bacterial endocarditis found in the aerodigestive tract. Although there are are found in Tables 3 and 4.33 no clinical studies to support the efficacy of antibiotics given prophylactically before dental treat- Prosthetic joints ment, splenectomized patients are clearly at in- Prosthetic replacement of the hip, knee, and creased risk of serious sepsis, and appropriate other joints because of arthritis, trauma, congenital antimicrobial prophylaxis should be considered. abnormalities, or previous surgical failure has be- come common in the United States.34 Infections of Renal disease these joints may result from contamination at sur- The typical streptococci and staphylococci asso- gery or hematogenous spread from another site, and ciated with dental bacteremias can contaminate commonly involve Staphylococcus aureus and Staphj' vascular-access sites used for dialysis or cause signifi- lococcus epidermidis species. Experiments in animals cant infection in immunocompromised transplant show that seeding of a prosthetic joint from distant recipients.40 Dental treatment is usually provided on sources of infection is possible.35 However, only a few the day after dialysis, and antimicrobial prophylaxis cases of joint infection resulting from foci of odonto- is recommended to prevent endarteritis and, possi- genic infections or transient bacteremia generated by bly, infective endocarditis.41 Transplant recipients dental procedures have been documented.36 require aggressive treatment of acute oral infections, Although most orthopedic surgeons believe in- including oral candidiasis, in addition to antimicro- fection of a prosthetic joint by transient dental bial prophylaxis.

222 CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 62 • NUMBER 4

Downloaded from www.ccjm.org on September 23, 2021. For personal use only. All other uses require permission. ORAL HEALTH • PYLE AND TEREZHALMY

Neutropenia In addition, about one third of patients develop a Given the predictability of bacteremias associ- second, separate oral malignant disease as a conse- ated with dental procedures and the risk of uncon- quence of multifocal malignant changes throughout trolled infection, it would seem reasonable to give the oral mucosa ("field cancerization").46 neutropenic patients antibiotics prophylactically Prevention and early treatment are essential to before dental treatment.42 Neutropenic patients control oral cancer. Health care providers should who are afebrile and clinically stable should receive inform patients of the relationship between to- a broad-spectrum antibiotic starting 1 hour before bacco or alcohol and oral cancer. This may be a dental treatment. Many neutropenic patients will challenging endeavor, especially with older pa- already have systemic infections and will be taking tients with established smoking and drinking hab- broad-spectrum antibiotics. In this situation, it may its. Additional factors implicated in the develop- be necessary to ensure the coverage of periodon- ment of oral malignant diseases include chronic topathic anaerobic organisms; either clindamycin or irritation from ill-fitting dentures, irregular or sharp metronidazole (oral or parenteral form) may need to teeth, hot or spicy food, ultraviolet radiation, infec- be added to the antibacterial regimen. tion, vitamin deficiency, and altered immunocom- petence. Diabetes mellitus The association of malignant diseases with spe- Diabetes mellitus currently affects more than 12 cific, predominant risk factors in the United States million Americans, and the number is growing at a results in a well-recognized anatomic distribution of rate of600 000 new cases per year. Many physiologic oral cancers. The four specific areas predisposed to changes associated with this condition decrease the the development of squamous cell carcinoma are the immune response and increase the chance of infec- lips, floor of the mouth, ventrolateral border of the tion. Studies have demonstrated a higher preva- tongue, and the complex involving the soft palate, lence of gingivitis, periodontitis, and caries in dia- retromolar trigone, and anterior tonsillar pillar.47 A betic patients than in the general population.43 diagnosis of advanced squamous-cell carcinoma is Rapid alveolar bone loss and acute infection appear not difficult to establish. Early lesions, however, are to be directly related to elevated blood glucose con- asymptomatic and frequently remain undetected. centrations and periods of uncontrolled diabetes. The association of a white patch or leukoplakia with Other oral manifestations of diabetes mellitus may oral cancer is well documented. Erythroplakia or include xerostomia, bilateral asymptomatic parotid- erythroplakia with leukoplakia are other important gland swelling, unexplained odontalgia, increased mucosal lesions that often indicate premalignant or susceptibility to opportunistic infections, and ace- malignant changes. tone on the breath.44 Although the presence of oral No malignant disease is easier to cure than oral or odontogenic infections in diabetic patients may cancer—if the tumor is smaller than 1 cm in diame- affect insulin requirements, and although both good ter. Unfortunately, because symptoms and size are diabetic control and oral hygienic measures are directly related, most lesions are not detected until needed to maintain or restore oral health, a recent they reach stage II (T2 or larger). When an asymp- study concluded that clinicians caring for diabetic tomatic red or white lesion is detected in the oral outpatients seldom note oral health problems.43 cavity, acute or chronic irritants should be re- moved, and the use of alcohol and tobacco should Oral cancer be determined and curtailed. Inflammatory lesions An estimated 31 000 cases of oral cancer were resulting from acute or chronic trauma markedly expected to be diagnosed in 1993.45 Because oral improve in 10 to 14 days. Any lesion that persists cancer is primarily a disease of older patients, and longer than 14 days with no apparent cause should because the mean age of the population is shifting be considered malignant until proven otherwise by upward, the incidence of both premalignant and biopsy. malignant oral lesions will likely increase corre- spondingly. In addition, patients who have had oral Cancer chemotherapy cancer are at risk of primary malignant diseases of Because chemotherapeutic agents are nonspe- the pharynx, esophagus, larynx, and lungs and are at cific, they adversely affect normal cells that have a high risk for recurrence of the primary oral cancer. high mitotic index, including those of the oral mu-

JULY • AUGUST 1995 CLEVELAND CLINIC JOURNAL OF MEDICINE 223 Downloaded from www.ccjm.org on September 23, 2021. For personal use only. All other uses require permission. ORAL HEALTH • PYLE AND TEREZHALMY

cosa. Oral effects of cancer chemotherapy include sels, edema, thrombus formation, and fibrosis lead to mucositis, infection, hemorrhage, xerostomia, mucositis, infection, soft-tissue necrosis, xeros- neurologic disorders, and nutritional problems.48 tomia, caries, loss of taste, osteoradionecrosis, and Tj^e severity of these conditions may be affected by physiologic, anatomic, and psychologic morbidity. patient- and therapy-related variables. Patient-re- Managing patients undergoing radiation therapy lated variables include the. oral health of the patient of the head and neck is a multidisciplinary responsi- before and during chemotherapy; therapy-related bility. Oral and dental care and maxillofacial reha- variables include the type of agent or agents used, bilitation should be coordinated both before radia- the dosage, the frequency of treatment, and whether tion therapy is started and when oral complications combination therapy is used. It is of paramount im- of radiation therapy develop. portance for the health care provider to recognize The objectives of dental treatment in these pa- and anticipate the conditions that predispose patients are (1) to avoid, through timely intervention tients to complications. Studies suggest that early and strong preventive measures, severe side effects and aggressive dental intervention according to such as caries and osteoradionecrosis; (2) to reduce standardized protocols reduces the frequency of oral morbidity and improve the quality of life for patients problems during chemotherapy.49 who develop certain inevitable side effects such as The objectives of dental treatment for patients mucositis, xerostomia, loss of taste, and infection; undergoing cancer chemotherapy are to (1) pre- (3) to ensure the survival of the natural dentition, vent morbidity and mortality caused by infection which will facilitate prosthetic rehabilitation when from an oral source by eliminating or minimizing osseous resection of the maxilla and mandible is these sources before the initiation of chemother- planned; (4) to implement a program of follow-up apy; (2) prevent oral hemorrhage by minimizing and long-term preventive care; and (5) to initiate the need for acute dental treatment during chemo- and maintain a program of patient education. therapy; (3) prevent delays or interruptions of che- Before starting radiation therapy, the patient motherapy caused by supervening acute dental should have a comprehensive clinical and radio- treatment during chemotherapy; (4) minimize the graphic regional examination that emphasizes con- frequency of serious oral mucosal infections caused ditions known to cause problems during or after by treatable viruses, fungi, and bacteria and mini- radiation therapy, such as infected or nonrestorable mize the impact of oral mucositis on the patient's teeth, advanced periodontal disease, impacted nutritional status; and (5) initiate and maintain a teeth, and other pathoses. When osseous resection program of patient education. of the maxilla or mandible is planned in addition to Before starting chemotherapy, patients should radiation therapy, preoperative casts and registra- have a comprehensive clinical and radiographic re- tions should be part of the initial workup. When- gional examination that emphasizes conditions ever possible, extraction of nonrestorable teeth and known to cause problems during chemotherapy, other oral surgical procedures should be completed such as infected or nonrestorable teeth, advanced 14 to 21 days before initiation of radiation therapy. periodontal disease, and oral mucosal ulcers. Emer- Patients with salvageable teeth should undergo an gent problems should be eliminated. Because of the intensive preventive maintenance program. potentially serious consequences of systemic exten- During radiation therapy, palliative and suppor- sion of infections, patients should be monitored dur- tive care can significantly reduce morbidity by pro- ing chemotherapy, and, when appropriate, diagnos- viding symptomatic relief of pain, mucositis, and tic and therapeutic services should be initiated for xerostomia. Regular examinations during this pe- herpetic, candidal, and other oral or odontogenic riod minimize infections and reinforce preventive infections. measures. After radiation therapy, daily applications of fluoride gel, the use of saliva substitutes and Radiotherapy of the head and neck sialagogues, increased oral hygiene efforts, and regu- Radiotherapy, effective in the treatment of many lar evaluation to assess compliance with the pre- head and neck cancers, produces progressive and scribed preventive care program will minimize mor- persistent cell damage and eventual cell death, not bidity. This strategy, combined with the restoration only within the tumor, but also within adjacent of orofacial function and appearance for patients normal tissue. Swelling and occlusion of small ves- with significant hard- and soft-tissue defects from

224 CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 62 • NUMBER 4 Downloaded from www.ccjm.org on September 23, 2021. For personal use only. All other uses require permission. ORAL HEALTH • PYLE AND TEREZHALMY

ablative surgery, will significantly improve the qual- will remain at risk of dental diseases. As future co- ity of life. horts of aging people face functional decline and As in other conditions, patients and their families debilitating diseases, the oral health they have en- should be fully informed about the importance of joyed may follow the path of general decline. oral and dental health, with particular emphasis on Dental professionals can play an integral role in its relationship to their disease. assisting multidisciplinary team efforts to optimize the functional ability and quality of life of older SUMMARY people. When systemic problems overlap oral health problems, physicians and dentists should coordinate Despite the impact of dental public-health initia- the care they give to more comprehensively address tives, preventive care, and education, the elderly the patient's total needs.

REFERENCES Welton RC. The frequency of sicca syndrome in an elderly fe- male population. J Rheumatol 1987; 14:766-771. 21. Sreenby LM, Schwartz SS. A reference guide to drugs and dry 1. National Center for Health Statistics. Current estimates from mouth. Gerodontology 1986; 5:75-99. the National Health Interview Survey, US, 1985. (Series 10, no 22. Nolan L, O'Malley K. Prescribing for the elderly, part II. Pre- 160) DHHS publication no (PHS) 86-1588. scribing patterns: differences due to age. J Am Geriatr Soc 1988; 2. National Center for Health Statistics. Basic data on dental ex- 36:245-254. amination findings of persons 1-74 years, US, 1971-74. Hyattsville, 23. Baker KA, Levy SM, Chrischilles EA. Medications with den- MD: National Center for Health Statistics, DEW pub no (PHS) tal significance: usage in a nursing home population. Spec Care 79-1662 (Vital and health statistics, series 11, no 214), 1979. Dentist 1991; 11:19-25. 3. US Department of Health and Human Services. Oral Health 24. Mazer MS. Geriatric pharmacology and dental implications. of United States Adults. National Findings. The National Survey Gen Dent 1992; 40:215-220. of Oral Health in US Employed Adults and Seniors: 1985-86. 25. Wallace MC, Retief DH, Bradley EL. Prevalence of root caries DHHA, PHS, NIH, NIH pub no 87-2868, August 1987. in a population of older adults. Gerodontics 1988; 4:84-89. 4. Gift HC, Redford M. Oral health and quality of life. Clin 26. Beck J. Epidemiology of root caries. J Dent Res 1990; 69:1216— Geriatr Med 1992; 8:673-683. 1221. 5. Dolan TA. Identification of appropriate outcomes for an aging 27. Faine MP, Allender D, Baab D, Persson R, Lamont RJ. Die- population. Spec Care Dentist 1993; 13:35-39. tary and salivary factors associated with root caries. Spec Care 6. Dolan TA. Identification of appropriate outcomes for an aging Dentist 1992; 4:177-182. population. Spec Care Dentist 1993; 13:37. 28. Beck JD. Epidemiologic changes in older adult periodontal dis- 7. Gordon SR, Jahnigen DW. Oral assessment of the dentulous ease. Gerodontology 1988; 7:103-107. elderly patient. J Am Geriatr Soc 1986; 34:276-281. 29. Ellen RP. Considerations for physicians caring for older adults 8. Gordon SR, Jahnigen DW. Oral assessment of the edentulous with periodontal disease. Clin Geriatr Med 1992; 8:599-616. elderly patient. J Am Geriatr Soc 1983; 31:797-800. 30. McDowell JD, Kassebaum DK. Diagnosing and treating halito- 9. Wayler AH, Chauncey HH. Impact of complete dentures and sis. J Am Dent Assoc 1993; 124:55-64. impaired natural dentition on masticatory performance and food 31. Johnson CM. Adherence events in the pathogenesis of infective choice in healthy aging men. J Prosthet Dent 1983; 49:427-433. endocarditis. Infect Dis Clin North Am 1993; 7:21-36. 10. Duthie EH, Lloyd PM, Gambert SR. Nutrition and the elderly: 32. King K, Harbnes JL. Infective endocarditis in the 1980's, Part I: implications for oral health care. Spec Care Dentist 1983; 3:201— Aetiology and diagnosis. Med J Aust 1986; 144:536-540. 206. 33. Dajani AS, Bisno AL, Chung KJ, et al. Prevention of bacterial 11. Mandel ID. The role of saliva in maintaining oral homeostasis. J endocarditis. Recommendations by the American Heart Associa- Am Dent Assoc 1989; 119:298-303. tion. JAMA 1990; 264:2919-2922. 12. Atkinson JC, Fox PC. Salivary gland dysfunction. Clin Geriatr 34- Harris WH, Sledge CB. Total hip and total knee replacement Med 1992; 8:499-511. (Part I). N Engl J Med 1990; 323:725-731. 13. Johanson WG, Pierce AK, Sanford JP. Nosocomial respiratory 35. Blomgren G. Hematogenous infection of total joint replace- infections with gram-negative bacilli. Ann Intern Med 1972; ments: an experimental study in the rabbit. Acta Orthop Scand 77:701-706. Suppl 1981; 187:1-64. 14. Gibson G, Barrett E. The role of salivary function on oro- 36. Cioffi GA, Terezhalmy GT, Tabos GM. Total joint replace- pharyngeal colonization. Spec Care Dentist 1992; 12:153-156. ment: a consideration for antimicrobial prophylaxis. Oral Surg 15. Baum BJ. Salivary gland fluid secretion during aging. J Am Oral Med Oral Pathol 1988; 66:124-129. Geriatr Soc 1989; 37:453-458. 37. Nelson JP, Fitzgerald RH, Jaspers MT, Little JW. Prophylactic 16. Fox PC, van der Ven PF, Sonies BC, Weiffenbach JM, Baum antimicrobial coverage in arthroplasty patients. J Bone Joint Surg BJ. Xerostomia: evaluation of a symptom with increasing signifi- Am 1990; 72-A:l. cance. J Am Dent Assoc 1985; 110:519-525. 38. Shaw JHF, Print CG. Postsplenectomy sepsis. Br J Surg 1989; 17. Sreenby LM. Dry mouth and salivary gland hypofunction, part 76:1074-1081. II: etiology and patient evaluation. Compend Contin Educ Dent 39. Terezhalmy GT, Hall EH. The asplenic patient: A considera- 1988; 9:630-638. tion for antimicrobial prophylaxis. Oral Surg Oral Med Oral 18. Atkinson JC, Fox PC. Sjogren's syndrome: oral and dental con- Pathol 1984;57:114-117. siderations. J Am Dent Assoc 1993; 124:74-86. 40. Keane WF, Shapiro FL, Faij L. Incidence and type of infections 19. Bone RC, Fox RI, Howell FV, Fantozzi R. Sjogren's syndrome: occurring in 445 chromic hemodialysis patients. Trans Am Soc a persistent clinical problem. Laryngoscope 1985; 95:295-299. Artif Intern Organs 1977; 23:41-46. 20. Strickland RW, Tesar JT, Berne BH, Hobbs BR, Lewis DM,

JULY • AUGUST 1995 CLEVELAND CLINIC JOURNAL OF MEDICINE 225

Downloaded from www.ccjm.org on September 23, 2021. For personal use only. All other uses require permission. ORAL HEALTH • PYLE AND TEREZHALMY

41. Naylor QD, Hall EH, Terezhalmy GT. The patient with lanta: American Cancer Society, 1992. chronic renal failure who is undergoing dialysis or renal transplan- 46. Toth BB, Martin JW, Lippman SM, Hong WK. Chemopreven- tation: another consideration for antimicrobial prophylaxis. Oral tion is a form of cancer control. J Am Dent Assoc 1993; 124:243- Surg Oral Med Oral Pathol 1988; 65:116-121. 246. 42. Otis, Terezhalmy GT. The granulocytopenic patient: another 47. Mashberg A, Myers H. Anatomical site and size of 222 early consideration for antimicrobial prophylaxis. Oral Surg Oral Med asymptomatic oral squamous cell carcinomas: a continuing pro- Oral Pathol 1985; 60:125-129. spective study of oral cancer. II. Cancer 1976; 37:2149-2151. 43. Jones RB, McCallum RM, Key, EJ, Kirbin V, McDonald P. 48. Naylor GD, Terezhalmy GT. Oral complications of cancer che- Oral health and oral healthy behavior in a population of diabetic motherapy: prevention and management. Spec Care Dentist outpatient clinic attenders. Community Dent Oral Epidemiol 1988; 8:150-156. 1992; 20:204-207. 49. Sonis S, Kunz A. Impact of improved dental services on the 44. Skoczylas IJ, Terezhalmy GT, Langlais RP, Glass BJ. Dental frequency of oral complications of cancer therapy for patients management of the diabetic patient. Compend Contin Educ Dent with non-head-and-neck malignancies. Oral Surg Oral Med Oral 1988; 9:390-399. Pathol 1988; 65:19-22. 45. American Cancer Society. Cancer facts and figures—1992. At-

IN EVERY ISSUE Cardiology Dialogues • Highlights from • Medical Grand Rounds Internal Medicine Board Review • Current Drug Therapy • i Interpreting Key Trials •

tínawí i Cancer Diagnosis « and Management SvS«»*'' M Clinical Reviews • ® CME Credit Test- > 2 hours Category I

226 CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 62 • NUMBER 4

Downloaded from www.ccjm.org on September 23, 2021. For personal use only. All other uses require permission.