Look in the Mouth!

Don’t neglect an oral health exam for older patients.

It is easy to be rushed and cut corners in the ED, and for my residents this often means a less than thorough (if any) examination of the mouth.  If the chief complaint is not “dental pain” or “sore throat” the mouth seems to fall off their physical exam list. This may not be as critical in the healthy 25-year-old, but for the older adult patient, the oral exam can often provide important diagnostic clues.  In addition to chief complaints of sore throat or dental pain, a mouth exam is an essential part of the medical workup for fevers, failure to thrive, dysphagia, headaches, pneumonia and shortness of breath.

Older adults are at higher risk for oral infections and chronic oral conditions that can affect their systemic health.  Daily hygiene may be neglected by the patient or caregivers due to physical or cognitive limitations or lack of caregiver education and training in oral health.

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Only 64% of adults ≥ 65 years old have had a dental visit in the past year.(¹⁾ Biases may contribute to this as well, as some people assume that patients without teeth do not need to see a dentist.  About a fifth of older adults are edentulous, and these patients still require oral evaluations.  This condition can actually predispose them to poor nutrition and complications from oral prosthetics (such as dentures).(²⁾

Additionally, routine checks and maintenance can pick up oral cancers earlier, and all older adults are at higher risk for these.  The physiologic changes of aging also place this population at higher risk for oral lesions and infections.(³⁾ An aging mouth is not an exception in an aging body, and with aging comes hyposecretion of salivary glands, changing stages in lining cells and resorption of soft and hard tissue (gum recession). Increased bacterial accumulation in the oral cavity leads to a higher risk of aspiration pneumonia.(⁴⁾ In addition to physiologic changes, multiple chronic health conditions and medications cause xerostomia (dry mouth), which also contributes to pain and difficulty eating. (⁵⁾

Figure 1: Periodontal disease in an older adult with lack of access to dental care

Patients with autoimmune diseases such as Rheumatoid Arthritis, Systemic lupus erythematosus, diabetes mellitus, autoimmune thyroid disease, multiple sclerosis and HIV/AIDs are at high risk for oral lesions and slow healing.(⁶⁾ Oral lesions may occur due to an ill-fitting removable oral prosthesis (dentures or bridges), trauma (falls) or simply as a result of bacterial or fungal accumulations (Figures 1, 2, and 3).

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Angular cheilitis is an infectious condition that should be treated with antibiotics or antifungals depending on the source, as well as a topical barrier product to prevent maceration and moisture damage from saliva.

Immunocompromised patients are also at higher risk for tooth loss and malnutrition.  Dietary deficiencies worsen these oral conditions and leads to a cyclic, negative reinforcement of disease.

Oral fungal infection causing reduced oral intake and dehydration in an older nursing facility patient.

Older adults with oral health issues can also present atypically.  Those with cognitive decline do not complain of pain as a 25-year-old with a dental abscess would, or may feel it as headaches or nausea or lack of appetite.  The first expression of oral pain is often decreased oral intake, presenting as dehydration and nutritional deficits.  In one study of ED patients ≥ 65 years old, 12% qualified as having malnutrition and of those, over half listed poor oral health as the cause.(⁷⁾

Think about it: how many older patients have you seen this past month who present with headaches, sepsis with unknown source, aspiration pneumonia, failure to thrive or poor oral intake, or concern for abuse/neglect?   All these patients should have a good oral exam and many will need urgent referral to a dentist as part of their care.  Every patient with aspiration pneumonia should be referred to a dentist for intensive preventative dental care to reduce bacterial overgrowth.   Any patient you intubate and note “poor dentition” in your note should have aggressive oral hygiene (by a dental team if possible) while in the ICU.(⁸⁾  Studies have shown that proper oral care can not only reduce the risk of future infections, but also reduce mortality from hospital acquired pneumonia.

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Many hospitals and long-term care facilities do not have dentists on staff and nurses and care givers may not have adequate training to care for oral health of the elderly.  Residents in long-term care facilities can develop dental/ oral diseases tend to have a serious problem, particularly when routine dental care is neglected.(⁹⁾  Actually looking in the patient’s mouth  and relaying the importance of good oral health back to the patient and caregiver  is more likely to improve that patient’s quality of life far more than the tetanus booster you just updated or the screening for tuberculosis your ED nurse did. Oral health is an essential part of all patients’ health, but it is especially critical for vulnerable older adults.  So next time… look in the mouth.

References:

1. National Center for Health Statistics, Center for Disease Control and Prevention. Health, United States, 2017 table 78. Dental visits in the past year, by selected characteristics. at https://www.cdc.gov/nchs/fastats/dental.htm.)
2. QuickStats: Prevalence of Edentualism in Adults Aged ≥65 Years, by Age Group and Race/Hispanic Origin — National Health and Nutrition Examination Survey, 2011–2014. Centers for Disease Control and Prevention, January 27, 2017. at https://www.cdc.gov/mmwr/volumes/66/wr/mm6603a12.htm.)
3. Delwel S, Binnekade TT, Perez R, Hertogh C, Scherder EJA, Lobbezoo F. Oral hygiene and oral health in older people with dementia: a comprehensive review with focus on oral soft tissues. Clin Oral Investig 2018;22:93-108.
4. Terpenning MS, Taylor GW, Lopatin DE, Kerr CK, Dominguez BL, Loesche WJ. Aspiration pneumonia: dental and oral risk factors in an older veteran population. J Am Geriatr Soc 2001;49:557-63.
5. Turner MD, Ship JA. Dry mouth and its effects on the oral health of elderly people. J Am Dent Assoc 2007;138 Suppl:15S-20S.
6. Ermann J, Fathman CG. Autoimmune diseases: genes, bugs and failed regulation. Nat Immunol 2001;2:759-61.
7. Burks CE, Jones CW, Braz VA, et al. Risk Factors for Malnutrition among Older Adults in the Emergency Department: A Multicenter Study. J Am Geriatr Soc 2017;65:1741-7.
8. Sjogren P, Wardh I, Zimmerman M, Almstahl A, Wikstrom M. Oral Care and Mortality in Older Adults with Pneumonia in Hospitals or Nursing Homes: Systematic Review and Meta-Analysis. J Am Geriatr Soc 2016;64:2109-15.
9. Sloane PD, Zimmerman S, Chen X, et al. Effect of a person-centered mouth care intervention on care processes and outcomes in three nursing homes. J Am Geriatr Soc 2013;61:1158-63.