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UCSF Oral Assessment Pocket Card

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UCSF Oral Assessment Pocket Card Oral Assessment Oral and Head/Neck Assessment Remove all oral prosthesis; dentures or partials For the Older Adult 1. Head normal posture: Inspect for masses or asymmetry. 2. Tilt head to the side: palpate cervical lymph nodes. Identification of a lesion: 3. Lips: palpate inside/outside with thumb and forefinger. History: duration of lesion and pain, symptoms, pain scale 4. Gingiva: reflect lips and examine visually, cheek (buccal) Location: lips (outer/inner) cheek (buccal), mucosa tongue, roof and tongue sides. of mouth, floor of mouth, gums (gingiva) 5. Buccal mucosa: with mouth half closed, use tongue blade to Clinical description: size, shape, color, consistency, exudates reflect lips (blood, purulent) 6. Palate: tip head back, have patient say “ahh”, note uvula, Teeth: tooth # or location (UR,UL,LL,LR) hard palate, and tonsils. Gingiva: recession, inflammation 7. Tongue: Have patient extend tongue, wrap 2x2 gauze Habits: smoking, tobacco use, alcohol, food/diet around anterior third and palate tongue between 2 fingers: Oral care assessment: current dentist, last dental visit, daily x Observe posterior portion routine and products Abnormal (swelling),Asymmetrical tenderness Firm palpable with tenderness, enlarged cracks,Dry, wounds, open ulcera- tions, bleeding, painful Inflamed, red, swollen,bleeds on pal- pation wounds, patchy, openulcera- Dry, tions, erythema wounds, patchy, openulcera- Dry, tions, swellings, erythema Dry, cracks, fissures, patchy, open wounds, ulcerations Patchy, open wounds, ulcerations Multiple missing,decayed, mobile or broken teeth, discolored , Thick sticky, minimal amount Unable to functionwear or comforta- bly, painful, broken or chipped parts. Debris: food, plaqueand tartar (calculus) x Lateral border: move tongue to one side to visualize entire lateral border, then repeat to other side. 8. Floor of mouth: have patient touch tip of tongue to palate- check underside of tongue and the floor of mouth palpate bimanually. 9. Palpate mandible and maxilla then check bite. 10. Saliva: amount and consistency. UR UL When to refer to the dentist: LR LL x All patients should have annual dental check ups Refer if any lesion persists longer than 2 weeks after initial visit Refer if lesion does not respond to initial treatment. Refer if lesion changes in appears (shape, size, or color) Developed By: Bonnie Lederman BSDH DDS, Normal Symmetrical palpable,withNo no discomfort Smooth, pink or melanin pigment) and moist Moist, pink or ( melanin pigment) tight around tooth Moist and pink or (melanin pigment) and Moist pink, rough (ridges: ante- portion rior only) Rough, pink andwith moist, vari- cosities on ventralsurface Moist pink with varicosities Minimal 20 teeth functionalwith whitishcontacts, solid, stable, Free flowingwatery and Solid unit, fits comfortablywith no rocking Free of debris: food, plaque and tartar (calculus) DENTAL PEARLS: UCSF Multidisciplinary Geriatric Fellow Contributions: x Older adults have higher risk of dental disease so implement Shelley Miyasaki DDS PhD, oral care prevention. Chief of Oral Maxillofacial Surgery SFVA x Document any oral clinical findings Roy Nakamoto DDS MS, Assistant Chief of Dental Services, Prosthodontic Site Director SFVA x Many older patients may have compromised capacity to Piri Veluppillai DDS, UCSF Dept. of Oral Medicine make decisions; capacity is decision specific - able to com- Eric Widera MD, Associate Professor of Clinical Medicine, municate a choice, understand the relevant information, UCSF Division of Geriatric appreciate the situation and its consequences and reason Supported by HRSA Geriatric Training Program for Physicians, Dentists, about treatment options and Behavioral and Mental Health Profession x If competence/capacity is an issue, get caregivers or family Please contact for additional copies of this card: member involved in their daily oral care Elaine Chow at [email protected] Structures Face Nodes Lips Gums (Gingiva) Cheek (buccal mucosa) Hard Palate/ Throat (posterior pharynx) Tongue Floor of mouth Teeth Saliva Artificial teeth Dentures/ Partials Oral Cleanliness Oral Condition /Etiology/ Description Treatment Aphthous ulcers: Mixing topical steroid ointments with equal parts of Orabase B paste promotes adhesion. Minor (Canker sore), Major: Heals with scarring, Herpetiform: Multiple small ulcers. Dexamethasone elixir 0.5mg/ 5 ml. 100 mL. Rinse with 1tsp (5mL) for 2 min q8h. Fluocinonide 0.05% compounded with equal parts Orabase (final solution) 0.025%, Applied 5x/d as soon as prodrome starts, then stop once lesion appears. Bisphosphonate Osteonecrosis (ONJ): Pen VK 500mg, 28 tabs, take 1 tab q6h for 7 days, or if Pen allergy; History of IV or oral use with NO history head and neck radiation treatment. Painful, Clindamycin 300mg, 21 tabs, take 1tab q8h for 7 days. Should be taken with 8 oz. of water. exposed bone mostly on gingiva. Chlorhexidine gluconate (non alcohol form) 0.12%, 473 mL. (16 oz). Rinse with 15 ml 2x/d for 30 seconds and spit, avoid rinsing and eating for 30 mins. Rinse after breakfast and bedtime. Burning Mouth Disorder: Rule out systemic conditions (Anemia) Add ¼ teaspoon baking soda and 1/8 teaspoon salt to 1 cup water, rinse several times/day, especially after meals. Xerostomia, fungal and chronic infection, allergic rxn, nutritional deficiencies, 2% viscous lidocaine HCl, swish and spit 5mL for 5 minutes q6h for pain. medications, Absence of clinical signs. Capsaicin 0.025% cream. 15 gm tube. Apply minor amounts to local area of burning q8h. Warn of a temporary local pain. Candidiasis: Topical: Pseudomembranous form (Thrush):Soft, white, plaque can be wiped off Clotrimazole (Mycelex) troches 10mg. 70 troches. Let 1 troche dissolve in mouth 5x/d. Do not chew or swallow. Erythematous form: Patchy or generalized erythematous sensitivity on palate/ Nystatin vaginal tablets 100,000 U. 70 tablets. Let tablet dissolve in the mouth 5x/d Do not chew, OK to swallow. Do not rinse for 30 mins. (Does not contains sugar). tongue (Median rhomboid glossitis). Systemic: Hyperplastic form: Confluent white areas cannot be wiped off. Fluconazole (Diflucan) tabs 100mg. 15 tabs. Take 2 tabs stat then 1 tab daily for 2 weeks. Angular cheilitis: corner of mouth; cracks, ulcers. Denture wearers: Properly clean the existing denture Keep denture out of the mouth for extended period. Soak for 30 mins in solution of CHX or 1% sodium hypochlorite and then thoroughly rinse. Nystatin ointment Apply a thin coat to the inner surface of the denture and the affected area after meals. Nystatin/mycostatin powder, clean denture than apply light coating BID am/afternoon. Contact stomatitis: Mouthwashes, Tartar control paste, Whitening agents, Sodium Discontinue agent lauryl sulfate, Cinnamon flavors; Sloughing, patchy, erythematous, painful tissue. Baking soda paste brush for 2 weeks, Biotene mild paste , Tom’s natural toothpaste. Caries (Hole in tooth): Brush after meals with fluoridated toothpaste (OTC), use Fluoride containing rinse (OTC) between meals, if unable to brush after meals. Discolored ( dark yellow to black), hard to soft lesion Dietary counseling to decrease frequency of sugar intake (carbonated drinks). Gingival recession leads to root caries Chew xylitol gum for 5 minutes between meals or after meals when unable to brush. Use 3-4 times daily between meals. PreviDent 1.1% gel (Neutral pH sodium fluoride), 1 tube. Place a 1 inch ribbon on toothbrush; brush thoroughly twice daily for 2 mins and then spit. Avoid rinsing or eating for 30 min. Dental-Odontogenic Infections: Pen VK 500mg, 28 tabs, take 1 tab q6h for 7 days, or if Pen allergy; Pathogen related to dental caries (extension of pulpal tissue) OR Clindamycin 300 mg, 21 tabs, takes 1tab q8h for 7 days. Should be taken with 8 oz. of water. Periodontal (gum) infections. Swelling of tissue around a tooth, fluctuant mass with or without a fistula. Pain may be localized to tooth. Denture Sore Mouth: Remove dentures for extend period of time( especially overnight). Fungal infection, Poor denture hygiene, ill-fitting dentures, or dry mouth. Improve oral and appliance hygiene. Soak dentures in denture cleanser. Erythematous, smooth or granular tissue. May have burning sensation. Antifungal meds (Candidiasis section) and Oral lubricant. Herpes Simplex: Prevention: PreSun (OTC) Intraoral: Single or small clusters of vesicles forms painful ulcers. Topical Antiviral Agents: Occurs on keratinized tissue (roof of mouth and /or gingiva). Penciclovir (Denavir) crm 1% 2 g tube. Dab on lesion every 2 hrs during waking hours for 4 days. Labialis: Cluster of vesicles of the lips and perioral region. Docosanol (Abreva) crm (OTC) 2 g tube. Dab on the lesion 5x/d during waking hours for 4 days. Treat early during prodromal stage: Valacyclovir (Valtrex) caplets 500mg. 8 caplets. Take 4 caplets as soon as prodromal symptoms occurs then 4 caplets 12 hrs later. Long term systemic antiviral therapy: Acyclovir (Zovirax) caps 200 mg. Take 400mg orally 3x/ d for 5-10 days Herpes Zoster (Shingles) Acyclovir (Zovirax) caps 800 mg. 35 caps. Take 1 caps 5x/ d for 7 days. Valacyclovir (Valtrex) caplets 500mg. 50 caplets. Take 2 caplets 3x/ for 7 days. Lichen Planus: Inform Patient: Chronic condition, no known cure. Treat if symptomatic. Reticular form: Lacy white lines (Wickham’s striae). Fluocinonide 0.05% compounded with equal parts Orabase (final solution) 0.025%. Coat the lesion with a thin film after each meal and at bed time for 2 months. Atrophic form: Erythematous form. Dexamethasone elixir 0.5 mg/5
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