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Medical Problems Complicate Their Care
As we age, we experience a number of significant age-related changes. Fortunately, most of these normal aging changes do not cause oral diseases. Instead, it is the cumulative effects of both oral and systemic diseases that account for the extensive pattern of oral disease among the elderly. It is interesting to note that increasing numbers of “well elderly” are able to retain their natural teeth and enjoy normal oral function throughout old age. For the frail elderly the situation is quite different. Shay and Ship provide an excellent overview of how oral and systemic diseases contribute to poor oral health in the elderly. They explain that, “loss of one or more teeth as a result of disease can predispose to further tooth loss, destruction of alveolar bone (the bone surrounding the teeth), dependence on and compromised function of prosthetic replacements (dentures), and mucosal disease.” The same oral diseases that lead to tooth loss also cause tooth sensitivity, pain, and impair chewing and speaking ability. In addition, lesions of the soft tissues of the mouth can interfere with mastication and can affect nutritional status.24 Oral cancers such as squamous cell carcinoma can cause extreme disfigurement and even death. Systemic diseases may directly or indirectly harm the oral cavity by altering saliva flow, which plays an essential protective role in the mouth. The effects of oral diseases are not limited to the oral cavity. Oral diseases can release blood-borne bacteria or cause bacteria to be aspirated into the lungs. A major impact of systemic diseases on the oral health of older adults is caused by the side effects of medications. With increasing age and associated chronic disease, the elderly are prescribed an ever-expanding variety of medications. Besides the desired therapeutic outcome, adverse side effects may alter the integrity of the oral mucosa. Problems such as xerostomia (dry mouth), bleeding disorders of the tissues, lichenoid reactions (oral tissue changes), tissue overgrowth, and hypersensitivity reactions may occur as a result of drug therapy. Ship and Chavez summarized these effects , which illustrates many of the oral health problems created by commonly prescribed medications. Cardiovascular diseases were the leading cause of death among the elderly in 1997, followed by cancer, stroke, chronic obstructive pulmonary diseases, pneumonia and influenza, and diabetes. For those over 85, heart disease accounted for 40 percent of all deaths. Beck, Offenbacher, Williams et al. and others have published research suggesting a possible link between cardiovascular and periodontal diseases, but more research is needed to clarify the findings. Heart diseases may trigger symptoms that appear in and around the oral cavity, such as when angina presents as pain in the neck, jaw, or teeth. Cancer, the second leading cause of death among the elderly, also has a significant impact on the oral cavity. Oral and pharyngeal cancers account for about 5 percent of all cancers, and they increase in prevalence with age. Cancer treatments including chemotherapy, radiation, and surgery can cause severe stomatitis (inflammation of the mouth), xerostomia (dry mouth), disfigurement, altered speech and mastication, loss of appetite, and increased susceptibility to oral infections—including those that cause caries and periodontal diseases. Stroke, pulmonary diseases, and diabetes are also common among the elderly. Each has important consequences in managing oral care for the elderly. In addition to these conditions, impairments in hearing, vision, and orthopedic function are the most common impairments among the elderly,
Drug Category Drug Oral Problem
Analgesics Aspirin Hemorrhage, erythema multiforme
NSAID
Barbiturates, Codeine Hemorrhage, erythema multiformre
Anesthetics (local) Benzocaine, Procaine, HCI Lidocaine Taste diorders
Antiarrhythmics Procainamide Lupus-like reaction
Quinidine Lichenoid mucosal reaction
Antiarthritic Allopurinol, Auronofin, Colchicine,
Dexamethasone Taste disorders
Antipyretic Hydrocortisone, Levamisole
Anti-inflammatory D-Penicillamine, Phenylbutazone, Salicylates
5-Thiopyridoxine
Gold salts Taste disorders, lichenoid reaction, oral
pigmentation vesiculoulcerative stomatitis
Antibiotics All Oral candidiasis
Erythromycin Hypersensitivity reaction, vesiculoulcerative stomatitis
Penicillin Hypersensitivity reaction, erythema multiforme,
vesiculoulcerative stomatitis
Chloramphenicol Erythema multiforme
Ciprofloxacin, Clindamycin, Dapsone, Isoniazid
Sulfa antibiotics, Tetracyclines
Minocycline Melanosis
Chlorhexidine Brown pigmentation of teeth and tongue
Ampicillin, Cefamandole, Ethambutol HC1
Griseofulvin, Lincomycin, Metronidazole,
Niridazole, Sulfasalazine, Tetracyclines
Anticoagulants All Hemorrhage
Anticonvulsants Carbamazepine Erythema multiforme, taste disorders
Phenytoin Erythema multiforme, gingival enlargement, taste disorders
Antidiarrhea Bismuth Dark pigmentation of tongue
Antihistamines All Salivary dysfunction
Chlorpheniramine maleate Taste disorders
Antihypertensives All Salivary dysfunction
Calcium channel blockers Gingival enlargement
ACEb inhibitors Vesiculoulcerative stomatitis, pemphigus vulgaris
Chloramphenicol Vesiculoulcerative stomatitis
Hydralazine Lupus-like reaction, erythema multiforme
Methyldopa Lupus-like reaction and lichenoid mucosal reaction
Thiazide diuretics Lichenoid mucosal reaction
Minoxidil, Verapamil Erythema multiforme
Acetazolamide, Amiloride Taste disorders
Captopril, Diazoxide, Diltiazem, Enalapril
Ethacrynic acid, Nifedipine
Antilipidemics Cholestyramine, Clofibrate Taste diorders
Antimicotics Griseofulvin Erythema multiforme, black pigmentation of tongue
Amphotericine B Taste disorder
Drug Category Drug Oral Problem
Antineoplastics All Oral candidiasis, oral hemorrhage, recurrent oral viral
infections, aphthous stomatitis, vesiculoulcerative stomatitis
Anti-Parkinsonian All Salivary dysfunction
Levodopa Taste disorders
Antireflux agents All Salivary dysfunction
Cimetidine Erythema multiforme
Antithyroids Carbimazole, Methimazole, Methylthiouracil Taste disorders
Propylthiouracil, Thiouracil
Antioxidants Octyl gallate Allergic ulcerations
Anxiolytics Benzodiazepines Salivary dysfunction
Chelating agents Penicillamine Ulcers and pemphigus vulgaris
Corticosteriods All Oral candidiasis, recurrent oral viral infections,
immunosuppressants vesiculoulcerative stomatitis
antiproliferatives
Azathioprine, Bleomycin, Carmustine Taste disorders
Doxorubirin, 5-Fluorouraci, Methotrexate, Gingival enlargement
Vincristine, Sulfate Cyclosporine
Hypoglycemics Sulfonylurea agents Erythema multiforme
Glipizide, Phenformin and derivatives Taste disorders
Muscle relaxants All Salivary dysfunction
Baclofen, Chlorzoxazone Taste disorders
Others Etidronate, Germine Monoacetate, Idoxuridine, Taste diorders
Iron Sorbitex, Vitamin D
Psychotherapeutics All Salivary dysfunction
Glutethimide, Meprobamate Erythema multiforme
Phenothiazines Oral pigmentation, tardive dyskinesia
Lithium carbonate Erythema multiforme, taste disorder
Trifluoperazine HCL Taste disorders
Sympathomimetics Amphetamines, Amrinone Taste disorders
Vasodilators Bamifyline HCL, Dipyridamole Taste disorders
Nitroglycerin patch, Oxyfedrine
a NSAIDs - nonsteroidal anti-inflammatory drugs.
b ACE - angiotensin converting enzyme. Source: Ship and Chavez.
and each has consequences for maintaining oral health.
Geriatric Diagnosis and Treatment Planning Are Complex