Specificities of clinical examination in geriatric dentistry
Course outline
- Introduction
- Definitions
- Epidemiological data
- General pathologies of the elderly
4.1 Gastrointestinal pathologies
4.2 Cardiopulmonary pathologies
4.3 Neuro-psychiatric pathologies
4.4 Endocrine pathologies
4.5 Leukomotor restrictions
- Determination of the nutritional profile
- Socio-economic and behavioral factors
- Practical conduct of the clinical examination
7.1 Examination of the mucous membranes
7.2 Language examination
7.3 Examination of the salivary glands
7.4 Examination of the teeth
7.5 Pathologies related to the wearing of dental prostheses
7.6 Examination of lymph node areas
7.7 Bisphosphonate-related osteonecrosis
Conclusion
- Introduction
Physiological aging, chronic pathologies and the psychosocial environment are sources of vulnerability in the elderly. These factors impact oral pathologies while oral diseases can conversely aggravate them and lead the patient into the spiral of decompensation. The clinical examination must consist of a global approach to the elderly person, which gives it its specific character.
Ettinger defined three categories of so-called “elderly” people:
– independent elderly patients;
– frail elderly patients;
– totally dependent elderly patients.
Internationally, the inclusion of geriatrics in dental curricula has been discussed since the 1970s. Current data indicate that geriatric dentistry is not a significant component of dental curricula.
- Definitions
2.1 Elderly person: for most authors an elderly person is a person who is 65 years old or older.
2.2 Dependence or (loss of autonomy): Dependence is the partial or total inability for a person to carry out, without human assistance, the activities of daily life, whether physical, psychological or social, and to adapt to their environment.
2.3 Aging : it is an inevitable, slow and progressive physiological process, which results in the weakening of the organism. It is the result of the intertwined effects of intrinsic (genetic) and extrinsic factors (eating habits, environment, etc.).
- Epidemiology
For most authors, an elderly subject is a person over 75 years old or over 65 years old and presenting several pathologies.
In Algeria:
It is reported that the population aged over 65 represents 6.5% or 3.4 million of the general population in 2018 and a projection of 12.5% or 7.2 million in 2040. The upward trend is universal, it is observed in all countries.
- General pathologies of the elderly patient
The number of general pathologies varies with age regardless of the patient’s level of dependency. Denton’s study shows that 90% of people over 65 suffer from a chronic pathology.
It is therefore understandable that age in itself represents a risk for the practitioner of finding himself confronted with a chronic pathology during dental treatments.
The various pathologies encountered in the elderly population have repercussions on
oral health status and care protocols and vice versa.
4.1 Gastrointestinal pathologies:
They are most commonly manifested by epigastric pain, gastroesophageal regurgitation, ulcers and hiatal hernias.
Oral: Most pathologies of this type manifest themselves by mucosal and periodontal changes (e.g., candidiasis, pain under prosthetics). Oral ulcers may appear in cases of Crohn’s disease. In gastroesophageal reflux, the change in salivary pH makes enamel abrasions frequent by acid attack.
4.2 Cardio-respiratory pathologies:
They are observed in all their forms: high blood pressure, heart failure, after-effects of strokes.
These pathologies require adequate oral care in order to limit superinfections. When they are in progress, they can lead to multiple extractions in order to eradicate the proven infectious foci. Untreated high blood pressure reduces resistance to stress and predisposes to accidents in the chair ranging from simple anxiety to heart attacks.
Oral infections can aggravate valvular disease. The passage of germs into the bloodstream, either spontaneously, i.e. from an infectious source, or caused by manipulation using instruments, results in bacterial grafting on the heart valves.
4.3 Neuropsychiatric pathologies:
Obsessive delusions, Parkinson’s disease and Alzheimer’s disease have a prevalence that tends to increase with age.
These pathologies have major oral repercussions. Most sialoprive polymedications predispose to numerous carious attacks.
Neurological problems complicate patient/practitioner communication, coping skills, and maintaining hygiene. They aggravate the local manifestations mentioned as well as eating disorders.
4.4 Endocrine pathologies:
The most frequently observed are usually type I or II diabetes. The prevalence of diabetes in elderly people living in institutions is 8.5%. This condition is one of the causes of the appearance of caries, especially of the neck, and nutritional problems.
Poorly balanced diabetes leads to extractions of pathological teeth to prevent the risk of infection. It reduces healing capacity and saliva rich in glucose predisposes to polycaries. An untreated oral infection can unbalance diabetes.
4.5 Locomotor restrictions :
They cause, most of the time, a delay in access to care due to the impossibility of traveling to the dental office. If there is an impairment of the upper limbs, gripping and movements necessary for brushing are difficult. Hygiene will be affected. Rheumatic pathologies such as polyarthritis cause the same effects.
Oral bacterial infections and inflammation appear to directly impact the negative evolution of chronic progressive polyarthritis.
Specificities of clinical examination in geriatric dentistry
- Determination of the nutritional profile:
Malnutrition has two main causes:
– Endogenous cause by hypercatabolism (general pathologies and infectious syndromes);
– Exogenous cause due to insufficient food intake.
Consequently, the clinical examination and the anamnesis must, in addition to the classic data, focus on the general health elements previously mentioned. The presence of serious psychiatric pathologies, gastrointestinal pathologies (dysregulation of intestinal absorption), cardio-respiratory insufficiency where eating requires effort (dyspnea on exertion) as well as strict diets must alert on the risk of malnutrition.
Clinically, some signs of malnutrition are easily detected by the practitioner: cheilitis, gingivo-dental lesions and the depapillated appearance of the tongue. When questioning the patient, questions concern the presence of tachycardia, dyspnea on exertion, vomiting, diarrhea and abdominal pain.
The dosage of pre-albumin and more commonly of albumin confirms a disorder of
nutrition (albumin Tx < 35 g/l). The MNA test is a simple method of assessing the nutritional level of an elderly person.
The intraoral examination reveals local pathologies specific to eating disorders, poor dental condition and eating habits that initiate a state of malnutrition.
Restoring masticatory function reduces the risk of malnutrition and prevents the worsening of general pathologies. It is advisable to first eradicate the pain, then in a second step to carry out functional rehabilitation very quickly.
- Socio-economic and behavioral factors
Many studies show a link between economic status and health status. The level of education has an impact on health status and on the use of care. People with a low level of education report more dental problems, more removable prostheses and less prevention. The link with income level goes in the same direction. Demand for fixed prostheses is greater in high socio-economic categories (in relation to income level) while those for extraction are more preponderant in groups with a low socio-economic level. Strategies for accessing prosthetic treatments therefore differ according to the level of material resources. People with low incomes are therefore exposed to a “renunciation phenomenon” of care.
- Practical conduct of the clinical examination
The dentist is required to see dependent elderly people in consultation. He may also be called upon for a patient hospitalized in a geriatric medicine, follow-up care and rehabilitation department, etc.
The clinical examination, which is sometimes difficult to perform, generally reveals poor or even non-existent oral hygiene, very poor dental and periodontal condition, and the frequent presence of mucosal lesions.
The reasons for consultation are, generally, the search for infectious foci of oral-dental origin, expressed or supposed oral pain, defective dental prostheses, etc.
This is most often a very “weakened” patient with multiple general pathologies whose care requires a secure technical platform.
The steps of the clinical examination of the elderly patient are no different from those used for other patients, except that the latter requires greater attention because very often they fail to report their ailments accurately, hence the importance of ensuring that they are listened to, given time and patience.
- The anamnesis must be complete and precise to best identify the oral and dental problems of our patients.
- All information collected must be mentioned on an observation sheet
Exoral examination:
Upon inspection and palpation, it is necessary to:
– Note the condition of the skin, the main reflection of aging and the integuments
– Assess the functionality of the masticatory system (TMJ, muscles, mandibular excursions)
– Look for the presence or absence of cervicofacial adenopathies.
– Evaluate the existing vertical dimension, assess the positioning of the lips, distinguish between physiological and pathological alterations (linked to the disappearance of teeth for example).
Intraoral examination:
Upon inspection and palpation, it is necessary to:
– Assess and detail the dental condition: teeth, missing, present, wear, abrasion, cracks and existing treatments.
– Study inter-arcade relationships.
– Assess the condition: periodontal, oral mucosa, effectiveness and possibility of oral hygiene.
– Diagnose oral and dental pathologies.
– With particular attention to salivary quantity and quality often affected by multiple drug treatments.
– Assess the condition of the tongue (smooth and depapillated in the event of taste disorders).
X-ray examinations:
A panoramic radiograph supplemented by retro-alveolar and retro-coronary radiographs is essential for:
- A general assessment of the oral health
- Detection of infectious foci and bone pathologies, evaluation of periodontal pockets
- Detection of carious processes.
Specificities of clinical examination in geriatric dentistry
7.1 Examination of the mucous membranes:
A study carried out in 2000 in the Essonne department on the “oral health of dependent elderly people” specifies that out of 308 subjects examined, 6% presented a pathology of the mucosa and 2% a traumatic ulceration.
Mucosal lesions are most often unrecognized and must be systematically sought.
They are favored by many factors including, naturally, the action of aging on tissues. But other factors sometimes induce these lesions:
- General pathologies,
- Drugs ;
- physical dependence;
- the mental state;
- malnutrition;
- wearing unsuitable dental prostheses.
- Leukoplakia:
Potentially malignant condition
- Squamous cell carcinoma:
The preferred location is the lower lip, tongue, gum, and floor of the mouth.
- Reactive keratoses:
Chronic prosthetic or dental trauma causes ulcerations, but also keratotic reactions.
Keratoses are often inhomogeneous:
- Warty, pearly white in color, firm in consistency and with more or less pronounced relief;
- Mixed, associating erosive areas within a keratotic formation.
These lesions must be treated with the greatest care because they are lesions with a potential risk of malignant transformation, especially if risk factors are added (tobacco, alcohol, etc.).
- Oral lesions of dermatological diseases
- Lichen planus : Probably of dysimmune origin, oral lichen planus is a chronic inflammatory skin and mucosal disease. Oral localization is more common than cutaneous lichen. This dermatosis evolves over several years to result in a scarring state called: post-lichen state. During this evolution, the lichen undergoes a succession of more or less inflammatory flare-ups and changes appearance to become atrophic or sclero-atrophic.
- Bullous dermatoses: Among these autoimmune lesions, with subepithelial detachment, bullous pemphigoid and cicatricial pemphigoid are more common in the elderly. They are part of chronic erosive gingivitis. The gums are very erythematous, shiny and painful to the touch. After lightly rubbing the gum, it is possible to detach the epithelium using tweezers, this is the forceps sign, in this positive case.
- Opportunistic infections:
- Candidiasis:
They are certainly the most frequently observed pathology in the elderly.
Acute diffuse forms are quite rare and mainly affect, apart from young children, the elderly and debilitated adults (in particular, during an HIV infection). They appear in the form of whitish efflorescences that are more or less florid and that are easily detached by simple scraping, revealing an erosive mucosa. Erythematous forms can be encountered where the whitish coating is little or not present, unlike pseudomembranous forms. There are also localized forms, mainly on the tongue and the palatine vault, with an erythematous or erythematopultaceous appearance. But it is the chronic forms in foci which dominate in the elderly: subprosthetic candidiasis, pseudomembranous or erythematous and atrophic candidal glossitis, median glossitis called diamond-shaped or rhomboid, median uranitis, candidal commissural cheilitis which is often associated with another oral candidal localization.
- Viruses: Rarer, but not exceptional in immunocompromised elderly people, are acute herpes infections ( Herpes virus ) and shingles ( Herpes zoster ), which is dreaded by its complications (post-zosteric pain). These contagious conditions in adults and the elderly require hospital treatment. The usual precautions should be taken during the clinical examination, given the risks of viral transmission.
7.2 Language examination:
- Atrophic glossitis: The back of the tongue may be the site of redness, atrophy of the papillae. The tongue may be completely smooth. These changes lead to altered taste and decreased appetite.
- Pliated tongue (fissured, scrotal): Very frequently observed and asymptomatic, apart from an exacerbated sensitivity to spices, alcohol and foods that are too hot or acidic, it is not really pathological but can be worrying because of its appearance: the dorsal surface of the tongue has multiple fissures and cracks, especially in the anteroposterior direction. There is no etiology found and no treatment to propose.
- Macroglossia : increase in the size of the tongue, in the elderly is mainly due to loss of tone of the cheek muscles or expansions or the oral cavity following tooth loss.
- Glossodynia or burning tongue : is observed in many elderly patients, sometimes with an atypical clinical picture. This may be due to vitamin deficiency.
7.3 Examination of the salivary glands:
In elderly patients, salivary flow is decreased resulting in xerostomia or dry mouth. It was assumed that dry mouth is a consequence of the aging process.
Currently, it is accepted that the etiology of xerostomia is medicinal.
(Antihistamines, antihypertensives, diuretics, antidepressants) and radiotherapy. Unfortunately, these drugs are often prescribed in adulthood and therefore xerostomia is considered a geriatric disease.
Examination of the salivary glands must be thorough due to the frequency of certain salivary pathologies in the elderly, namely:
- Benign or malignant tumor pathology
- Sclerosing dystrophic submandibulitis
- Salivary calcinosis
- Gougerot-Sjogren syndrome or dry syndrome.
Specificities of clinical examination in geriatric dentistry
7.4 Examination of the teeth:
Edentulism is common among older adults worldwide and is strongly associated with socioeconomic and educational levels. Epidemiological studies show that people with low socioeconomic status are more likely to be edentulous than people with high social class.
Dental caries and periodontal disease are the main reasons for tooth extraction.
Smoking is also a risk factor for tooth loss, especially in people who have been smoking heavily for many years.
7.5 Pathologies related to the wearing of dental prostheses
7.5.1 Stomatitis under prosthetics :
It is a common oral mucosal lesion caused by dentures in elderly populations. In many cases of subdenture stomatitis, yeast colonization on the intrados of the prosthesis is the origin of this stomatitis. Subdenture stomatitis is strongly linked to oral hygiene.
Other factors may be incriminated:
- Prosthesis not removed at night.
- Nighttime soaking of the prosthesis not respected.
- Using the wrong soaking products
7.5.2 Traumatic ulceration: These are frequent and related to old prostheses, unsuitable hooks or trauma from a damaged tooth. Vigilance is required because the pain is rarely verbalized by the patient.
Both lesions are more common in prosthesis wearers than in people with removable partial dentures.
Traumatic ulcers should disappear quickly (8 to 15 days) after removal of the irritating cause. If this is not the case, a biopsy is necessary.
7.5.3 Fibroepithelial hyperplasia : This is a common lesion in patients with old and unsuitable removable prostheses due to bone resorption linked to aging. This leads to repeated suction and sucking movements causing evagination of the mucosa, creating fibrous hyperplasia in the form of ridges sometimes shaped like “book pages”. The locations are most often located at the vestibule or the anterior pelvic-lingual groove. Surgical excision with histopathological control and rehabilitation of the prostheses will be the course of action.
7.5.4 Commissural cheilitis (angular cheilitis, angular cheilitis): This is a fungal infection favored, among other things, either by the physiological collapse of the labial commissure (muscle wasting in the elderly), or by the reduction in the vertical dimension of occlusion in relation to old and worn prostheses, and the lack of tissue support. A collapse of the commissural fold is created which favors maceration linked to the oozing of acid saliva, an environment favorable to candidiasis and bacterial superinfections. Angular cheilitis is often accompanied by another oral candidal location, in particular sub-prosthetic.
A vitamin deficiency or iron deficiency anemia, frequently associated, will be investigated and treated.
7.6 Examination of lymph node areas
An examination of the cervical lymph node areas will complete the clinical examination.
The search for possible adenopathy is an integral part of any diagnostic approach. Persistent lesions, after removal of the cause, must be biopsied before benefiting from excision according to oncological principles.
7.7 Osteonecrosis linked to bisphosphonates
They are increasingly frequently observed in the elderly.
These drugs can be divided into two groups:
- Bisphosphonates are used mainly in the treatment of malignant osteolysis (bone metastases from breast and prostate cancers, etc.), malignant hypercalcemia, etc. The role of these molecules (pamidronic and zoledronic acids) administered parenterally in cases of osteonecrosis of the jaws is now beyond doubt (incidence close to 1% with zoledronic acid);
- Bisphosphonates used in the treatment of non-oncological pathologies (post-menopausal and cortisone osteoporosis), administered orally (Bonviva®, Fosamax®, Didronel®, Actonel®, Aclasta®, etc.).
Specificities of clinical examination in geriatric dentistry
Conclusion :
The aging of the population is accompanied by an increased demand for care in stomatology and maxillofacial surgery. The practitioner is confronted with numerous pitfalls in his approach to elderly patients (fragile terrain, polymedication, random participation of the patient, etc.).
In these patients, the risk of under-medicalization or over-medicalization is significant. All of these considerations sometimes prompt the practitioner to choose his therapeutic approach in terms of quality of life for his patient. To do this, we emphasize the importance of dialogue with the patient and his family.
Specificities of clinical examination in geriatric dentistry
Wisdom teeth can be painful if they are misplaced.
Composite fillings are aesthetic and durable.
Bleeding gums can be a sign of gingivitis.
Orthodontic treatments correct misaligned teeth.
Dental implants provide a permanent solution for missing teeth.
Scaling removes tartar and prevents gum disease.
Good dental hygiene starts with brushing twice a day.