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THE MOST COMMON DISEASES OF
ORAL MUCOSA IN GERIATRIC
PATIENTS.
DIAGNOSIS AND TREATMENT.
AGE CHANGES :
 Changes in oral mucosa structure
 Decrease of saliva secretion due to increasing amount of fat
cells,lymphocytes and fibrosis in all salivary glands
 decrease of immunity
 systemic diseases
 more catabolic than anabolic processes
lek.dent Monika Hemerling
AGE CHANGES IN ORAL MUCOSA :
 stratum corneum- increase of ortokeratosis → risk of
planoepitelioma cancers
• In geriatric patients oral mucosa becomes
pale, atrophic and more prone to
mecanical, chemical and bacterial
reactions .
 stratum spinosum – reduction of thickness →
frequent ulcerations
 basal layer- hyperactivity of melanocytes → dark
pigmentation
• The inflammation lasts longer, clinical
symptoms might be less intensive but
there is a higher risk of complications.
 submucsal membrane - reduction of elastic fibres
LEUKOPLAKIA
Currently defined as a predominantly
white lesion of the oral mucosa that
cannot be characterized as any other
definable lession.
Etiology :
 Tabacco
 Alcohol abusement
 Vitamines deficiency (A,B)
 Chronic irritation (chronic cheek biting,
ill-fitting dentures, sharp teeth)
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WHO division of leukoplakia :
a) homogeneous
Three clinical stages of leukoplakia
I. The earliest lesion is nonpalpable, faintly translucent,
and has white discoloration.
b) non-homogenous
1. Erythroleukoplakia
2. Verrucous leukoplakia
3. Speckled leukoplakia
II. Localized or diffuse, slightly elevated plaques with an
irregular outline develop. These lesions are opaque
white and may have a fine, granular texture.
III. In some instances, the lesions progress to
thickened, white lesions, showing induration,
fissuring, and ulcer formation.
Clinical criteria demonstrate a particularly
Localization :
• Buccal mucosa
( commisure)
• Hard palate
• Lateral and ventral
tongue
• Floor of mouth
high risk of malignant change :
 The verrucous type is considered high risk.
 Erosion or ulceration within the lesion is highly
suggestive of malignancy.
 The presence of a nodule indicates malignant potential.
 Leukoplakia of the anterior floor of the mouth and
undersurface of the tongue is strongly associated with
malignant potential.
Differential diagnosis :
• Lichen planus
• Hyperplastic candidiosis
• Chemical/ termal burn
• White sponge nevus
• Leukoedema
• Linea Alba
Treatment :
Discontinue the use of tabacco and
alcohol
Topical retinoids
Excision modalities : surgery,
cryotherapy, carbon dioxide laser,
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LICHEN PLANUS
Clinical variants of oral lichen planus:
• Skin and oral mucosa disease of unknown etiology
(autoimmunological or immunological factors?)
Reticular ( Wickham’s striae)
Plaque-like
 Papular
Atrophic
• It occures in fourth to eighth decade, more often
among females (60%).
• Nervous and susceptible people are more prone to
develope lichen planus.
Erosive (ulcerative)
• The oral lesions may form before, after or at the same
time as the skin lesions.
Clinical presentation :
bilateral and often symmetric
distribution
buccal mucosa (most common)
 tongue
 gingivae
 lips
Differential diagnosis :
 Leukoplakia
 ( Shiller’s test)
 Lupus erythematosus
 Lichenoid drug eruption
 Ertyhema multiforme
 Reticular, plaque –like and papular variants tend to
be asymptomatic, often noticed incidentally by the
patient, although a sensation of ‘roughness’may be
present.
 Both atrophic and erosive types are very painful and
cause a lot of discomfort while speaking and eating.
Atrophic lesions present as irregular areas of
erythematous mucosa.
 Erosive eruptions are described as irregular areas of
epithelial destruction, covered with a yellow fibrin.
Geriatric patients often present extensive erosive lesions
due to mucosa susceptibility to mechanical irritation.
Treatment :

topical corticosteroids (mild and moderate cases)
Hydrocortison
 systemic immunosuppression (severe cases)
Prednisolone, Ciclosporin
 antiseptics Chlorhexidine
 analgesics Lignocaine rinse

retinoids
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PEMPHIGUS
Varieties of pemphigus :
 Immunobullous disorder that affects the skin
and mucous membrane.
 It is characterized by the presence of
autoantibodies to intercellular substance in the
stratum spinosum of epitelium. The intraepitelial
bullae are produced as a result of acantholysis
- the brakedown of the intracellular connections.




p. vulgaris
p. vegetans
p. erythematosus
p. foliaceus
 Half of all initial lesions are found in the mouth.
 Oral lesions develop in 70% of cases.
Clinical presentation :
Pemphigus vulgaris
is the most
common variety in geriatic patients.
It begins as fragile bullae that rapidly
brake down with the formation of
shallow, irregular and painful ulcers.
Differential diagnosis :
 Pemphigoid – direct
immunofluorescence(IMF) -antibodies at
the stratum spinosum of affected epitelium
Erosive lichen planus
buccal mucosa
 lips
 palate
 tongue
 gingivae (desquamative gingivitis)
Treatment :
• Corticosteroids
• systemic immunosuppression
• antiseptics
 Erythema multiforme
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PEMPHIGOID
Subtypes of pemphigoid :
• Bullous Pemphigoid ( BP) - predominantly affects the
• Immunobullous disorder characterized by the
formation of supepidermal bullae and the
presence of immunoreactants at the basement
skin and occasionally mucosa
• Mucous Membrane Pemphigoid (MMP) – involves
mucosa and occasionally skin
membrane zone.
The onset of MMP varies from under 30-70 years of age
but is morre common in late middle to old age( 50-70
years age group) There is 2:1 preponderance of female
patients
Clinical presentation :
 supepidermal bullae may remain intact for number of
days
 bullae are in general painless but there may be
Differential diagnosis :
Pemphigus vulgaris- direct
immunofluorescence- antibodies at
basement membrane zone
discomfort while forming and after rupture
 ulcerations of buccal mucosa, palate, tongue, lips
 gingivae (desquamative gingivitis)
Erythema multiforme
Erosive lichen planus
CANDIDIASIS :
Treatment :
 topical corticosteroids
Oral candidiasis is predominately caused by
Candida albicans, although other related
Candida species may be involved.
Candida is a commensal organism and part of the
normal oral flora in about 30% - 50% of the
population.
It is capable of producing opportunistic infections
within the oral cavity when appropriate
predisposing factors exist.
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Predisposing factors in geriatric
patients :
 Xerostomia
 Antibiotic therapy
 Corticosteroid therapy
 Poor oral or denture hygiene
 Malnutrition/Gastrointestinal malabsorption
 Iron, folic acid, or vitamin deficiencies
 Acidic saliva/Carbohydrate-rich diets
 Radiation therapy/Chemotherapy
 Diabetes mellitus and other systemic diseases
The most common variant in elderly
patient is Chronic Atrophic Candidiasis.
It is often associated with a poorly
fitting dentures and known as
“denture - sore mouth”.
Clinical Presentation :
Differential diagnosis :
red and painful mucosa on denture-bearing
surface
usually on hard palate and dorsal tongue but
may be also find on other parts of oral cavity
on hard palate frequently associated with
papillary hyperplasia
patients may complain of a burning sensation
may also be asymptomatic
• Allergic or irritant contact stomatitis
• Atrophic lichen planus
Treatment :
!! It is important to remember to treat both : denture (if present) and
oral tissues. (The denture will act as a reservoir for the Candida
and reinfect the tissues if they are not treated concurrently).
! It is recommended to use topical antifungal agents, directly to the
oral lesions or used as a liquid wash.
! Resistant infections or reccurences should be treated with systemic
medications.
Antifungal drugs are available in various forms :
lozenges, pastilles, creams, suspensions.
Poliene agents :
Nystatin, Amphotericin B
Azole agents :
Fluconazole, Itraconazole,
Ketoconazole
!! Ketoconazole can cause changes in
liver function
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ANGULAR CHEILITIS
(angular stomatitis, cheilosis,
perleche)
Etiology :
• Candida spp.
• Streptococus spp.
• Staphylococus
aureus
Multifactorial condition with a number of local and
systemic predisposing factors.
Predisposing factors :
Clinical presentation :
inadequate dentures with reduced vertical
deep, red cracks at the corners of the
dimension
skin creasing with saliva leackage and
maceration at corners of the mouth
 systemic diseas or deficiency (wit.B group)
poor oral higiene
decrease or increase of saliva flow
hypoferric anaemia, megaloblastic anaemia
Treatment :
mouth,often covered with a pseudo membrane
if severe, the splits or cracks may bleed when
the mouth is opened and a shallow ulcer or a
crust may form
burning sensations possible
Burning Mouth Syndrome
( stomatodynia in older terminology)
o Antimicrobial and antifungal therapy
ex. Daktarin 2% gel ( Miconazole )
o Vitamin B
BMS occurs most commonly among
postmenopausal women ( seven times as
often as men), although it affects many
other people as well. It is caused by many
conditions.
o New dentures with correct vertical
dimension
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Causing factors :
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Diabetes
Haematinic deficiences – vitamin B12, iron, folate
Salivary glang hypofunction
Candidosis
Parafunctional habits (chronic trauma)
Gastro-oesophageal reflux disease ( GORD)
Allergy to restorative or denture materials
Depression
Some people with burning mouth
syndrome don't wake up with mouth pain,
but find that the pain intensifies during the
day and into the evening. Some awake with
a constant daily pain, while others feel pain
on and off throughout the day.
Clinical presentation :
 localized burning sensation
(tongue,lips,gums,palate)
 generalized burning sensation
 normal appearance of oral mucosa
ZOSTER( Shingles)
 Caused by Varicella-Zoster DNA
virus morphologically similar to
the HSV.
 Most patients with Zoster are
middle-aged or older men.
TREATMEMT:
very difficult
depends on the underlying cause
Clinical presentation :
•
unilateral vesicular eruption in an
area of distribution of a sensory
nerve
•
the prodromal pain and tenderness
may last for 2-3 days
• in mouth vesicles rapidly break
 Shingles eruptions represent the
reactivation of the virus in a
previously infected patients.
 Zoster virus may remain latent in
the sensory ganglions for many
years.
The complications of the condition are
very often in geriatric patients:
 postherpetic neuralgia of trigeminal nerve
Paraesthesias
down and form ulcers
• The trigeminal nerve is involved
taste disturbances
in about 15% of cases, the
optalmic devision is most frequently
affected.
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Treatment :
IRON DEFICIENCY ANAEMIA :
Causing factors :
 antiviral drugs ( Acyclovir )
 ISOPRINOSINE
 Vitamin B1, B12, C
 inadequate intake of iron
 excessive blood lost ( gastrointerstinal
bleeding).
Oral symptoms :
MEGALOBLASTIC ANAEMIA :
•
 Caused by atrophy of gastric mucosa and consequent
•
•
•
•
•
atrophy of oral mucosa
atrophy of tongue epitelium (lost of filiform
papillae) = depillated tongue
angular cheilitis
taste disturbances
itching ( glossodynia most frequently)
pale oral mucosa
Oral symptoms :
 raw, beefy tongue
 pale oral mucosa
 sore mouth and tongue
failure of intrinsic factor (IF) necessary for absorption
of vitamin B12
 Vegans who avoid eating all food of animal origin may
also become deficient in vitamin B12
 Certain intestinal disorders such as Crohn's disease can
also lead to vitamin B12 deficiency.
 This disease occurs world-wide, but is commonest in
Northern Europeans.
 The peak age of onset is 60 and it is more common in
women than in men.
ORAL SYMPTOMS IN DIABETES
MELLITUS:
 Diabetes mellitus is a common endocrine disorder that
occurs as a result of a deficiency of insulin or resistance
to insulin.
 Two clinical types are recognized:
* Juvenile onset – type 1
* Maturity onset –type 2
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Oral symptoms :
VARICES:
 an abnormal venous dilatation
•
•
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•
•
 congenital or from demage to vessel wall
dry mouth and increase of saliva vicsosity
glossodynia- BMS
candidosis
compromised periodontal health
prolonged healing
oral mucosa more prone to injury
( trauma, ultraviolet light)
 occur with increasing frequency over 50 years of age
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