Diagnosis and management of oral mucosal conditions commonly seen in the elderly population
- recognise the older adult as a unique subset of patient;
- develop familiarity with the appearance and aetiology of various oral mucosal conditions that can present in the older adult; and,
- develop awareness of common treatment modalities for oral mucosal diseases.
Ageing may be defined as the age-progressive decline in intrinsic physiological function. However, due to advances in medicine, the rate of mortality has reduced and the older population is ever increasing. Indeed, the proportion of the Irish population aged 65 and over is expected to double over the next 20 years from 11% in 2006 to 22% in 2041.1 The older population is more likely to have a high burden of comorbidities and, as such, a higher incidence of oral disease, including oral mucosal diseases. The oral mucosa is subject to various age-related changes (Table 1). Although the oral mucosa is not subject to the same environmental threats as the skin, such as UV light and air pollution, it is exposed to a barrage of irritants throughout life. Masticatory trauma and resident microflora cause a constant influx of inflammatory and immune cells. Elastic changes may lead to a higher incidence of trauma and infection complicated by a poorer response of the immune system. The oral mucosa may also suffer the effect of polypharmacy, which is defined as the concurrent use of five or more medications. According to a report published by The Irish Longitudinal Study on Ageing (TILDA), one in three Irish adults over 65 report polypharmacy.2
The purpose of this article is to provide an overview of the common oral mucosal lesions seen in the older patient that may present to the general dental practitioner (GDP), and their management.
Common oral mucosal findings in an elderly population
Many soft tissue variations may be seen during the intra-oral soft tissue examination of an elderly patient. Therefore, variations of normal should be easily recognised and diagnosed by the GDP. Examples of these include lingual varices, fissured tongue and atrophic tongue.3
Lingual varices are dilated veins that may be seen on the ventral surface of the tongue. Their pathogenesis may be related to changes in the connective tissue and/or weakening of the venous walls during the ageing process. There is an increased incidence of lingual varices in the older population, and a correlation with cardiovascular disease and smoking has also been noted.4
Fissured tongue is characterised on clinical examination by a central groove on the dorsal surface of the tongue, with multiple laterally extending, branching fissures (Figure 1). Its incidence increases markedly with age and it can be considered a variation of normal findings and a result of the ageing process.5
Fissured tongue is usually asymptomatic unless accompanied by inflammation, which may be caused by low-grade bacterial infection or trapped food debris. Atrophy of the filiform papillae on the dorsal surface of the tongue can result in pain, soreness, or a burning sensation of the tongue.
Oral mucosal diseases
Oral mucosal diseases are more common among the elderly. Three common oral mucosal conditions associated with the older population are: salivary gland hypofunction and/or xerostomia; oral lichen planus (OLP); and, the vesiculobullous conditions.
Oral cancer is not a common malignancy seen in the elderly; however, it is more common in this age group than in the younger population.
Salivary gland hypofunction
Saliva has many functions, including:
- maintaining a moist oral mucosa that is less susceptible to abrasion;
- clearance of micro-organisms, desquamated epithelial cells, leucocytes and food debris; and,
- acting as a buffer to protect the oral, pharyngeal and oesophageal mucosae from ingested or regurgitated acid.
Salivary gland hypofunction or hyposalivation is an objective reduction in whole salivary flow rates (unstimulated rate of <0.1ml/min).6 Xerostomia is defined as the subjective complaint of dry mouth. Both conditions are common among the elderly and may be related to the use of xerogenic drugs, including (but not limited to): anticoagulants; antidepressants; antihypertensives; antiretrovirals; hypoglycaemics; levothyroxine; and, non-steroidal anti-inflammatory drugs. The impact of dry mouth on the oral mucosa includes the development of smooth surface caries, ill-fitting dentures, and soreness associated with denture wear. Patients can also have difficulty with speech and swallow, and are more prone to candida infection.5