THE MOST COMMON DISEASES OF ORAL MUCOSA IN GERIATRIC PATIENTS. DIAGNOSIS AND TREATMENT.

AGE CHANGES :
Changes in oral mucosa structure Decrease of saliva secretion due to increasing amount of fat
cells,lymphocytes and fibrosis in all salivary glands

decrease of immunity systemic diseases more catabolic than anabolic processes lek.dent Monika Hemerling

AGE CHANGES IN ORAL MUCOSA :

stratum corneum- increase of ortokeratosis risk of
planoepitelioma cancers

In geriatric patients oral mucosa becomes

pale, atrophic and more prone to mecanical, chemical and bacterial reactions .

stratum spinosum reduction of thickness

frequent ulcerations

The inflammation lasts longer, clinical

symptoms might be less intensive but there is a higher risk of complications.

basal layer- hyperactivity of melanocytes dark

pigmentation

submucsal membrane - reduction of elastic fibres

LEUKOPLAKIA
Currently defined as a predominantly white lesion of the oral mucosa that cannot be characterized as any other definable lession.

Etiology :

Tabacco
Alcohol abusement Vitamines deficiency (A,B) Chronic irritation (chronic cheek biting,
ill-fitting dentures, sharp teeth)

WHO division of leukoplakia :

a) homogeneous b) non-homogenous 1. Erythroleukoplakia 2. Verrucous leukoplakia 3. Speckled leukoplakia

Three clinical stages of leukoplakia

I. The earliest lesion is nonpalpable, faintly translucent, and has white discoloration. II. Localized or diffuse, slightly elevated plaques with an irregular outline develop. These lesions are opaque white and may have a fine, granular texture. III. In some instances, the lesions progress to thickened, white lesions, showing induration, fissuring, and ulcer formation.

Clinical criteria demonstrate a particularly

Localization :
Buccal mucosa
( commisure)

high risk of malignant change :

The verrucous type is considered high risk. Erosion or ulceration within the lesion is highly
suggestive of malignancy.

Hard palate Lateral and ventral

tongue

The presence of a nodule indicates malignant potential. Leukoplakia of the anterior floor of the mouth and
undersurface of the tongue is strongly associated with malignant potential.

Floor of mouth

Differential diagnosis :

Treatment :
Discontinue the use of tabacco and
alcohol

Lichen planus Hyperplastic candidiosis Chemical/ termal burn White sponge nevus Leukoedema Linea Alba

Topical retinoids Excision modalities : surgery,

cryotherapy, carbon dioxide laser,

LICHEN PLANUS
Skin and oral mucosa disease of unknown etiology
(autoimmunological or immunological factors?) among females (60%). develope lichen planus.

Clinical variants of oral lichen planus:

It occures in fourth to eighth decade, more often Nervous and susceptible people are more prone to The oral lesions may form before, after or at the same
time as the skin lesions.

Reticular ( Wickhams striae) Plaque-like Papular Atrophic Erosive (ulcerative)

Clinical presentation :
bilateral and often symmetric
distribution

Reticular, plaque like and papular variants tend to

be asymptomatic, often noticed incidentally by the patient, although a sensation of roughnessmay be present.

Both atrophic and erosive types are very painful and

cause a lot of discomfort while speaking and eating. Atrophic lesions present as irregular areas of erythematous mucosa.

buccal mucosa (most common) tongue gingivae lips

Erosive eruptions are described as irregular areas of

epithelial destruction, covered with a yellow fibrin. Geriatric patients often present extensive erosive lesions due to mucosa susceptibility to mechanical irritation.

Differential diagnosis :

Treatment :

topical corticosteroids (mild and moderate cases)

Leukoplakia ( Shillers test) Lupus erythematosus Lichenoid drug eruption Ertyhema multiforme

Hydrocortison

systemic immunosuppression (severe cases)

Prednisolone, Ciclosporin

antiseptics Chlorhexidine analgesics Lignocaine rinse

retinoids

PEMPHIGUS
Immunobullous disorder that affects the skin
and mucous membrane.

Varieties of pemphigus :

It is characterized by the presence of

autoantibodies to intercellular substance in the stratum spinosum of epitelium. The intraepitelial bullae are produced as a result of acantholysis - the brakedown of the intracellular connections.

p. vulgaris p. vegetans p. erythematosus p. foliaceus

Half of all initial lesions are found in the mouth. Oral lesions develop in 70% of cases.

Clinical presentation :

Pemphigus vulgaris

is the most

common variety in geriatic patients. It begins as fragile bullae that rapidly brake down with the formation of shallow, irregular and painful ulcers.

buccal mucosa lips palate tongue gingivae (desquamative gingivitis)

Differential diagnosis :
Pemphigoid direct immunofluorescence(IMF) -antibodies at the stratum spinosum of affected epitelium Erosive lichen planus Erythema multiforme

Treatment :

Corticosteroids systemic immunosuppression antiseptics

PEMPHIGOID

Subtypes of pemphigoid :
Bullous Pemphigoid ( BP) - predominantly affects the
skin and occasionally mucosa

Immunobullous disorder characterized by the

formation of supepidermal bullae and the presence of immunoreactants at the basement membrane zone.

Mucous Membrane Pemphigoid (MMP) involves

mucosa and occasionally skin The onset of MMP varies from under 30-70 years of age but is morre common in late middle to old age( 50-70 years age group) There is 2:1 preponderance of female patients

Clinical presentation :
supepidermal bullae may remain intact for number of
days

Differential diagnosis :
Pemphigus vulgaris- direct immunofluorescence- antibodies at basement membrane zone Erythema multiforme Erosive lichen planus

bullae are in general painless but there may be

discomfort while forming and after rupture

ulcerations of buccal mucosa, palate, tongue, lips gingivae (desquamative gingivitis)

CANDIDIASIS : Treatment :
Oral candidiasis is predominately caused by Candida albicans, although other related Candida species may be involved. Candida is a commensal organism and part of the normal oral flora in about 30% - 50% of the population. It is capable of producing opportunistic infections within the oral cavity when appropriate predisposing factors exist.

topical corticosteroids

Predisposing factors in geriatric patients :

Xerostomia Antibiotic therapy Corticosteroid therapy Poor oral or denture hygiene Malnutrition/Gastrointestinal malabsorption Iron, folic acid, or vitamin deficiencies Acidic saliva/Carbohydrate-rich diets Radiation therapy/Chemotherapy Diabetes mellitus and other systemic diseases

The most common variant in elderly patient is Chronic Atrophic Candidiasis. It is often associated with a poorly fitting dentures and known as denture - sore mouth.

Clinical Presentation : Differential diagnosis :

red and painful mucosa on denture-bearing
surface usually on hard palate and dorsal tongue but may be also find on other parts of oral cavity on hard palate frequently associated with papillary hyperplasia patients may complain of a burning sensation may also be asymptomatic

Allergic or irritant contact stomatitis Atrophic lichen planus

Treatment :
!! It is important to remember to treat both : denture (if present) and oral tissues. (The denture will act as a reservoir for the Candida and reinfect the tissues if they are not treated concurrently). ! It is recommended to use topical antifungal agents, directly to the oral lesions or used as a liquid wash. ! Resistant infections or reccurences should be treated with systemic medications.

Poliene agents : Nystatin, Amphotericin B Azole agents : Fluconazole, Itraconazole, Ketoconazole !! Ketoconazole can cause changes in liver function

Antifungal drugs are available in various forms : lozenges, pastilles, creams, suspensions.

ANGULAR CHEILITIS (angular stomatitis, cheilosis, perleche)

Etiology :
Candida spp. Streptococus spp. Staphylococus
aureus

Multifactorial condition with a number of local and systemic predisposing factors.

Predisposing factors :

Clinical presentation :
deep, red cracks at the corners of the
mouth,often covered with a pseudo membrane

inadequate dentures with reduced vertical

dimension skin creasing with saliva leackage and maceration at corners of the mouth systemic diseas or deficiency (wit.B group) poor oral higiene decrease or increase of saliva flow hypoferric anaemia, megaloblastic anaemia

if severe, the splits or cracks may bleed when

the mouth is opened and a shallow ulcer or a crust may form

burning sensations possible

Treatment :

Burning Mouth Syndrome ( stomatodynia in older terminology)

o Antimicrobial and antifungal therapy

ex. Daktarin 2% gel ( Miconazole ) BMS occurs most commonly among postmenopausal women ( seven times as often as men), although it affects many other people as well. It is caused by many conditions.

o Vitamin B o New dentures with correct vertical

dimension

Causing factors :

Clinical presentation :

Diabetes Haematinic deficiences vitamin B12, iron, folate Salivary glang hypofunction Candidosis Parafunctional habits (chronic trauma) Gastro-oesophageal reflux disease ( GORD) Allergy to restorative or denture materials Depression

localized burning sensation

(tongue,lips,gums,palate)

generalized burning sensation normal appearance of oral mucosa

Some people with burning mouth syndrome don't wake up with mouth pain, but find that the pain intensifies during the day and into the evening. Some awake with a constant daily pain, while others feel pain on and off throughout the day.

ZOSTER( Shingles)
Caused by Varicella-Zoster DNA
virus morphologically similar to the HSV.

Most patients with Zoster are

middle-aged or older men.

TREATMEMT: very difficult depends on the underlying cause

Shingles eruptions represent the

reactivation of the virus in a previously infected patients.

Zoster virus may remain latent in

the sensory ganglions for many years.

Clinical presentation :

unilateral vesicular eruption in an area of distribution of a sensory nerve the prodromal pain and tenderness may last for 2-3 days

The complications of the condition are very often in geriatric patients:

postherpetic neuralgia of trigeminal nerve

in mouth vesicles rapidly break

down and form ulcers

Paraesthesias taste disturbances

The trigeminal nerve is involved

in about 15% of cases, the optalmic devision is most frequently affected.

Treatment :

IRON DEFICIENCY ANAEMIA :

Causing factors :

antiviral drugs ( Acyclovir ) ISOPRINOSINE Vitamin B1, B12, C

inadequate intake of iron excessive blood lost ( gastrointerstinal

bleeding).

Oral symptoms :

MEGALOBLASTIC ANAEMIA :
Caused by atrophy of gastric mucosa and consequent
failure of intrinsic factor (IF) necessary for absorption of vitamin B12 Vegans who avoid eating all food of animal origin may also become deficient in vitamin B12 Certain intestinal disorders such as Crohn's disease can also lead to vitamin B12 deficiency. This disease occurs world-wide, but is commonest in Northern Europeans. The peak age of onset is 60 and it is more common in women than in men.

atrophy of oral mucosa atrophy of tongue epitelium (lost of filiform papillae) = depillated tongue angular cheilitis taste disturbances itching ( glossodynia most frequently) pale oral mucosa

Oral symptoms :

ORAL SYMPTOMS IN DIABETES MELLITUS:

Diabetes mellitus is a common endocrine disorder that
occurs as a result of a deficiency of insulin or resistance to insulin.

raw, beefy tongue pale oral mucosa sore mouth and tongue

Two clinical types are recognized:

* Juvenile onset type 1 * Maturity onset type 2

Oral symptoms :

VARICES:

an abnormal venous dilatation

congenital or from demage to vessel wall

dry mouth and increase of saliva vicsosity glossodynia- BMS candidosis compromised periodontal health prolonged healing oral mucosa more prone to injury

( trauma, ultraviolet light)

occur with increasing frequency over 50 years of age

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