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BOOMERS TO TUMORS: YOUR GROWING GERIATRIC DENTAL PRACTICE

Functional Categories

Functionally Independent
— Failing health, living at home without care — One or more handicaps, living at home with care — In nursing home or long term care facility

Basic Dental Rights: Minimally Invasive Dentistry
Free
of Infection
Swelling

Differential Diagnosis of Jaw Pain in the Elderly

1. Neoplasm
Squamous Cell Carcinoma 95% of all oral cancers Central ulceration with peripheral, rolled border;

Implications of Medical History:

1.
Angina, Congestive Heart Failure, hypertension 4. Arthritis 5. Colostomy 6. Inappropriate (Serax®) 10 - 15 mg 30 min prior to appointment (Ativan®) 0.5 - 1.0 mg 30 min prior to appointment least invasive procedure to restrain (physical or pharmacological)
versus oral sedation versus IV sedation versus General Anesthesia Principles of Prescribing Medications for the Elderly:
1.
Take a careful drug history of habits and use. Know the pharmacology of each drug prescribed. Titrate drug dosage with patient response. Simplify the therapeutic regimen and encourage compliance. Regularly review the treatment plan and discontinue drugs no longer needed.
Anti-coagulation Control:
Platelets:
PLT < 30K do not brush, floss; consider CHG rinse Adjust Coumadin level for surgery; pack with GelFoam #4 / Spongostan, always suture INR ≤ 2.0-2.5 for surgery, ≤ 3.5 for scaling Treatment on non-hemodialysis days for CRF / hemodialysis
Caution using epinephrine if CAD history:
Contraindicated with certain medications: No epinephrine-impregnated retraction cord
Local anesthetic choice - based on procedure length:
Ester local anesthetics (procaine - Novocain®, benzocaine topical) require optimal renal function
Factors affecting treatment plan decisions:



Classifications of Dental Care
(based on functional level, prognosis, etc.)
Class

Staged Treatment Plan:

Stage I -

On-site Long Term Care Facility Oral Hygiene List of Basic Supplies:
1. Disposable
(Wrapped tongue blades, facecloth, etc.)
Collis Curve Toothbrushes:
Collis Curve Canada
Dorothy Palmer
3632 Logan Crescent SW
Calgary, AB
800-298-4818 403/ 246-3302 dorpal@telusplanet.net
Web-sites:
Journal
, technology training & information
Burning Mouth Syndrome

Differential diagnosis includes:

xerostomia
candidiasis
chronic
psychogenic factors including factitious lesions (i.e. habit induced)

Typical work-up includes:

CBC and differential, glucose, iron, ferritin, folic acid and B12

Classic therapy
would suggest one or a combination of: topical anesthetics (viscous lidocaine or
benadryl elixir), antidepressants (e.g. clonazepam 0.25mg h.s., increase 0.25mg/wk to total dose
of 3mg/d, should try at least one month before outcome is known), or “live with it”.
Capsaicin compounds (from use in chemotherapy patients: Berger A., Yale Science Update, Fall
1994):
Edentulous patients can use the Zostrix 0.025% cream as a liner in their denture (tid - qid).
The problem is finding a friendly pharmacy that likes to formulate their own compounds.
Following are the formulations we most typically use: (patients can often make these up
themselves)
Capsaicin Candy: (problem - can have sharp edges which can be irritating)
Dissolve 2 C. brown sugar in 1/4 molasses, 1/2 C. butter, 2 Tbs. water and 2 Tbs. vinegar over low
heat in a heavy pan. Boil gently, stirring frequently until the hard-crack stage (300 degrees F, the
temperature at which a spoonful of candy separates into hard and brittle threads when dropped
into cold water). Add 1/2 tsp. cayenne pepper. Drop candy from a teaspoon onto a buttered slab
or foil to form patties. Makes about one pound.
Capsaicin Taffy: (softer, but more difficult to make)
Combine 1 C. Sugar, 3/4 C. light corn syrup, 2/3 C. Water, 1 Tbs. Cornstarch, 2 Tbs butter or
margarine, 1 tsp. salt and cook over medium heat, stirring constantly to 256 degrees F (candy
thermometer) or to the hard ball stage. Remove from heat. Stir in flavoring (e.g. 2 tsp vanilla) and
1/2 tsp. cayenne pepper. When cool enough to handle, pull taffy. When stiff, pull into strips, cut
into pieces and wrap.
Make clear to the patient that they will experience an initial burn. Usually, the burn of the
capsaicin is no more intense than the pain they already experience and it will subside shortly after
they begin using the cream or candy regularly. If they get a positive effect, this does not seem to
cure, rather a decrease in symptomology is found which typically needs re-treatment.
Management of Oral Candidiasis

Types of oral candidiasis
(a.k.a. "thrush", moniliasis, "yeast" infection):
Pseudomembraneous

Topical therapy (oral "swish and swallow"):
5 ml. p.o. swish for 1 minute then swallow t.i.d. X 10 d apply t.i.d. indicated for angular cheilitis or under denture
Systemic therapy:
caution with history of alcohol-abuse, cirrhosis, HBV, HCV Contraindicated in patients taking cyclosporin (transplants, etc.), Prepulsid
Note:
With any therapy, symptoms will disappear within 2-3 days, however, because the candidal
hyphae grow into the surface of the tissue, prolonged therapy (7 - 10 days) is required to prevent
immediate recurrence.
If the patient has any type of oral prosthesis, explain to the patient that the candidal hyphae can
grow into the surface of the acrylic, thus the denture needs to be “treated” as well. Have the
patient soak their dentures in vinegar (NOT bleach) overnight during treatment.
Management of a Dry Mouth (Xerostomia)
Saliva functions: protect the oral cavity
- Protection of tissues
Common causes of xerostomia:
Drugs or medications with anticholinergic effect - Aqueous solvent for taste & swallowing depression; emotional and anxiety states
Anti-depressants are the most likely iatrogenic cause of a dry mouth.
Common anti-depressants with the greatest anti-cholinergic potency:
Dry Mouth Questions:
1. Do you sip liquids to aid in swallowing dry foods? Management by dose reduction and / or substitution: 2. Does your mouth feel dry when eating a meal? 3. Do you have difficulties swallowing any foods? 4. Does the amount of saliva in your mouth seem to be too little, or too much, or don’t you notice?
Management of Xerostomia:
Keep mouth moist:
Biotene products - available over the counter (800/ 667-3770, www.laclede.com) Artificial saliva products are available, but many complain of objectionable taste. Water-based moisturizing products on lips: e.g. Blistex, K-Y Jelly, Dermabase Avoid petroleum-based lip products eventually cause more peeling and cracking: Humidifier in sleeping and / or work area.
Emphasize good oral hygiene; consider topical fluoride treatment, chlorhexidine rinses or toothpastes.
Avoid tobacco, alcohol, caffeine, salt which all have a drying effect. Careful with most mouthwashes
which contain high concentrations of alcohol.
Gentle dentistry:
use only alginate, polyvinyl siloxane or silicone; not ZOE consider building in a fluid reservoir in the base design
Salagen (pilocarpine)
then double third dose fifth week, so that daily protocol: 10 mg - 5 mg - 10 mg - 5 mg Incremental increase in dosage to a maximum of 30 mg / day titrated to optimal outcome and side effects (sweating, urinary frequency, chills, flushing, GI upset) Overhead Ceiling Mounted Patient Lifts

Waverley Glen (North America)

Chiltern Invadex Ltd Wispa Lifts (Europe UK)
EXAMPLES OF MEDICATIONS WHICH CAUSE XEROSTOMIA / DRY MOUTH:
Brand Name:
Generic Name:
Brand Name:
Anorexiants:
Anti-hypertensives:
Anti-acne:
Anti-anxiety:
Anti-inflammatory analgesics:
Anti-nauseant:
Anti-spasmodics:
Anti-Parkinsonian:
Anti-psychotics:
Anti-convulsants:
Anti-depressants:
Bronchodilators:
Decongestants:
Diuretics:
Anti-diarrheals:
Anti-histamines:
Muscle relaxants:
Narcotic analgesics & Sedatives:

Source: http://vdds.com/documents/GeriatricDentistryHandOut-TreyPettyDDS.pdf

Donna e

DONNA E. STEWART, MD, FRCPC REFEREED PUBLICATIONS Stewart DE . Treatment patterns in Canadian women with urinary incontinence: A need to improve case identification. Journal of Women’s Health (in press). Chiarelli A, Stotland N, Sloan P, Stewart DE , Mai V, Howlett R. Influence of physician and patient characteristics on adherence to breast cancer screening recommendations. Eur

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