Annals of Long-Term Care: Clinical Care and Aging. 2014;22(3):40-42.
Affiliations: 1Division of Geriatrics, Department of Family Medicine, Michigan State University, East Lansing, MI; 2Family Medicine Residency Program, Sparrow Hospital, East Lansing, MI
Abstract: Oral health is often neglected in older adults, particularly those in long-term care facilities. To help address this issue, physicians and other healthcare professionals should routinely perform oral health assessments, including for patients wearing dentures. These assessments could be integrated into routine physical examinations or when an oral health problem is identified. In this article, the authors report the case of a patient who developed mastication-associated rhinorrhea after many years of using a dental device. Upon the patient noting this troubling symptom, the authors performed a thorough oral examination, which enabled them to identify the etiology and recommend an intervention that would have been successful had the patient followed through.
Key words: Dentures, dental plates, oral assessments, oral health, rhinorrhea.
Increasing age predisposes people to a variety of oral health problems, such as loss of dentition, difficulty chewing, dysphagia, and xerostomia.1,2 These problems often pave the way for more serious systemic ailments, including weight loss and pneumonia, which can negatively impact morbidity and health outcomes.3-5 In addition, aging is associated with osteopenia of the facial bones and subtle changes to the connective tissues of the skin, sinuses, and oral cavity. Collectively, these changes are responsible for the distinguishing morphological features of the face, mandible, and orbits of the elderly population,6 and they can lead to unusual clinical consequences. To avoid such issues, elderly patients should regularly receive oral cavity examinations; however, the oral cavity is often overlooked during physical examinations. A variety of barriers to effective oral health have been described in the literature, including cognitive impairment, physical limitations, economic factors, and limited access to care.1,7
In this article, we report our experience with an elderly male patient who presented with an unusual symptom of rhinorrhea upon chewing solid food. We determined that the patient’s symptoms were caused by a combination of age-related changes and a previously performed dental procedure. A focused clinical assessment enabled us to identify a diagnostic intervention that would have successfully resolved his symptoms had he been able to follow through. With the case report, we provide a tip sheet that outlines how to conduct thorough oral evaluations in elderly patients with removable dental devices, which can help prevent oral health problems in these patients with unique oral care concerns. You can download the tip sheet here>>
An 85-year-old elderly man presented to our office for a routine visit. His medical history included hypertension, osteoarthritis, and borderline type 2 diabetes mellitus controlled with diet. His medications included warfarin sodium 5 mg daily, acetaminophen 500 mg twice daily, pravastatin 20 mg daily, lisinopril 5 mg daily, digoxin 0.25 mg daily, and a multivitamin. He reported no pain, difficulty chewing, dysphagia, heartburn, weight loss, chest pain, shortness of breath, sneezing, or allergic symptoms, but described experiencing a frequently runny nose. Upon further inquiry, he stated that his runny nose only occurred while eating as he chewed solid food. Consumption of fluids and softer consistency foods did not trigger his runny nose, and he had no associated headaches, vision changes, jaw pain, or claudication. He reported having regular visits with his dentist.
The patient had no history of asthma, nasal polyps, or sinusitis, and his medications were unchanged for the last 5 years. A recent colonoscopy was normal. He had no history of any head and neck surgery, but he did undergo cataract surgery with intraocular lens implantation in 2001. He had no history of smoking or use of recreational substances and did not drink alcohol. He reported no environmental exposure to chemicals and no allergies except intolerance to disopyramide phosphate and quinidine.
On physical examination, he was afebrile and had normal vital signs, with a blood pressure of 130/70 mm Hg, pulse rate of 70 beats per minute, and a respiration rate of 16 breaths per minute. Examination of his oral cavity revealed an upper removable metallic dental plate, whereas his lower dentition revealed some age-related changes but relatively intact teeth. His gums appeared normal with no oral ulcers or mucosal irritation. There was no lymphadenopathy noted in his neck region, and his thyroid gland was not palpable. Head and neck, cardiovascular, respiratory, central nervous system, and abdominal examinations were normal. The patient wore a functional hearing aid, and an otoscopic examination showed a normal-appearing ear canal and eardrum. We noted mild osteoarthritic changes in both of the patient’s knees and hands. Laboratory examinations showed no abnormalities.
We asked the patient to chew a piece of gum to see if his symptoms would reoccur. Within a few seconds of chewing, clear nasal drainage started flowing from his nostrils. He was prompted to stop chewing and to discard the gum, and a few minutes later the rhinorrhea stopped completely. Different consistencies of food were tried and the rhinorrhea was present with all food requiring mastication. Swishing or gargling liquid was observed to have no association with his runny nose. We then had the patient remove his dental plate and initiated the same tests; however, his symptoms were not reproducible when the plate was removed.
Based on these findings, the patient was referred to his dentist for a revaluation of his dental plate and fitting. We recommended that he be fitted with a new dental plate to resolve his mastication-associated rhinorrhea. He declined the recommendation, citing economic factors.
Pathophysiology of Our Patient’s Condition
Glandular secretions from the nasopharynx are mediated through parasympathetic cholinergic fibers. The nerve endings of these fibers are located in the mucous membranes of the nose, soft palate, hard palate, tonsils, uvula, gums, and upper pharynx, and they synapse in the pterygopalatine ganglion with the parasympathetic fibers from the facial nerve, which is responsible for mediating secretory activities in the pharyngeal region.8 In our patient’s case, osteopenia of the palatine bone paired with the dental plate exerting significant pressure on his palate while chewing solid food resulted in excitation of the nerve endings of the palatine branch, causing rhinorrhea upon mastication of solid food. The pathophysiological mechanism of the patient’s symptoms is further substantiated by the absence of rhinorrhea upon consumption of liquids and soft foods and upon removal of the dental plate itself.
Although our case report illustrates a rare clinical scenario, it also highlights the importance of oral examinations in elderly patients, including those with removable devices. These assessments are often overlooked in clinical practice, including in long-term care (LTC) settings. Currently, there are no national assessments of oral health in nursing homes; however, several states have evaluated residents using a survey developed by the Association of State and Territorial Dental Directors.9 One such state is Kansas, which surveyed 540 elders living in 20 nursing facilities throughout Kansas in 2012.10 Of the survey participants, more than 33% had untreated dental decay, 26% had severe gingival inflammation, 29% had substantial oral debris on at least two-thirds of their teeth, and 15% had natural teeth that were loose. Based on these findings, the survey advisory panel determined that many LTC residents are not removing the plaque and bacteria from their teeth on a regular basis. Despite these findings, the survey also found a high prevalence of previous dental work among the survey participants (eg, crowns, bridges, partial dentures), indicating past access to and investment in professional dental care that did not continue through their current life situation.10
Compared with natural teeth, dentures may be easier for elders and their caregivers to clean and care for, but patients with these appliances are not without potential problems. Denture use can lead to significant oral changes, which may negatively impact the integrity of oral tissue. For example, inappropriate fitting and care of dentures can lead to stomatitis, a chronic inflammation of the mucous membranes under the dentures due to an overgrowth of bacteria and yeast. The prevalence of denture stomatitis has been reported to range from 15% to more than 70%, with the prevalence increasing with age.11 In 2011, a resident at a nursing home in Kentucky developed potentially life-threatening denture stomatitis because the nursing home staff never realized that this individual wore dentures, causing the resident to wear them continuously for 6 months.12 As a result of this case, the nursing home lost its federal funding and had to close for a period of time. This incidence highlights the ramifications of poor oral screenings and care on both patients and institutions.
Historically, oral health has been regarded as the responsibility of dentists or others healthcare disciplines. However, as our case and the other aforementioned case show, a proactive approach on the part of physicians in screening and identifying a potential problem could significantly contribute to the health and wellbeing of elders and avoid complications from dental decay, gum disease, poor-fitting dentures, and other oral health issues. In addition, such proactive approaches are an integral part of providing holistic care, which has the potential to facilitate more meaningful patient-centered care and improved quality of life for all elderly residents. The tip sheet that follows this article outlines our clinical approach to conducting a comprehensive oral examination in elderly patients with dentures, and we urge you to share it with your colleagues.
Regular oral health screenings are essential for all elders, but require particular attention in patients with dental implants, removable plates, and other dental devices, as these appliances can lead to changes in the oral environment that can have a negative impact on health and wellbeing. Although dental care providers have historically conducted oral health screenings, it is essential for physicians to regularly conduct these examinations in their elderly patients, as many of these individuals may have stopped seeking dental care, leaving potential problems unidentified and unaddressed. By conducting these examinations, physicians can provide their elderly patients with holistic, patient-centered care.
1. US Department of Health and Human Services: Institute of Dental and Craniofacial Research. Oral Health in America: A Report of the Surgeon General. Rockville, MD: National Institute of Health Database; 2000. www.nidcr.nih.gov/DataStatistics/SurgeonGeneral/sgr. Accessed March 4, 2013.
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3. Thorstensson H, Johansson B. Does oral health say anything about survival in later life? Findings in a Swedish cohort of 80+ years at baseline. Dent Oral Epidemiol. 2009;37(4):325-332.
4. Shimazaki Y, Soh I, Saito T, et al. Influence of dentition status on physical disability, mental impairment, and mortality in institutionalized elderly people. J Dent Res. 2001;80(1):340-345.
5. Bassim CW, Gibson G, Ward T, Paphides BM, Denucci DJ. Modification of the risk of mortality from pneumonia with oral hygiene care. J Am Geriatr Soc. 2008;56(9):1601-1607.
6. Singhal S, Chand P, Singh BP, et al. The effect of osteoporosis on residual ridge resorption and masticatory performance in denture wearers. Gerodontology. 2012;29(2):e1059-1066.
7. Longhurst RH. Availability of domiciliary dental care for the elderly. Prim Dent Care. 2002;9(4):147-150.
8. Gray H. Anatomy of the Human Body. Philadelphia, PA: Lea & Febiger; 1918.
9. Saint Louis C. In nursing homes, an epidemic of poor dental hygiene. New York Times. August 4, 2013:D1. http://nyti.ms/1e80ms6. Accessed February 19, 2014.
10. Kansas Bureau of Oral Health. Elder smiles 2012: a survey of the oral health of Kansas seniors living in nursing facilities. www.kdheks.gov/ohi/download/2012_Elder_Smiles_Report.pdf. Accessed February 19, 2014.
11. Gendreau L, Loewy ZG. Epidemiology and etiology of denture stomatitis. J Prosthodont. 2011;20(4):251-260.
12. Spears VH. Nursing home resident’s dentures ‘corroded’ from lack of care. Kentucky.com. http://www.kentucky.com/news/special-reports/article44089146.html. Published April 11, 2011. Accessed February 19, 2014.
Disclosures: The authors report no relevant financial relationships.
Acknowledgments: The authors would like to thank Zakia Alavi, MD, for assistance during manuscript preparation.
Address correspondence to: Raza Haque, MD, Division of Geriatrics, Department of Family Medicine, Michigan State University, 788 Service Road, #B111, East Lansing, MI 48824-7046; email@example.com