NMDA Journal Summer 2018

21 nmdental.org and older. Thirty thousand Americans are diagnosed with oral pharyngeal cancers annually, the majority of cases occurring in the elderly. Silverman reports that 95% of oral pharyngeal cancers occur after the age of 40. Unfortunately, the last several decades have seen an increased incidence rate—up 15% from the 1970s.  23 It is more important than ever for every general dentist, hygienist and other health care workers to incorporate simple oral screenings into their standard treatment routines, since it is reported that about 75% of oral cancers can be detected by clinical findings and palpations of the head, neck and oral cavity.  24 Immunosuppression in the elderly presents a risk for the development of genetic mutations and precancerous conditions.  22 Another risk factor is smoking and exposure to tobacco products, and this risk is compounded when in conjunction with alcohol intake. Infection by the Human Papillomavirus (HPV16) has also emerged as a risk factor.  22 Early detection and diagnosis of oral cancers rely not only on the professional but on compliance by the patients. Appropriate yearly oral cancer screenings must be done on patients of all ages and demographics, especially as aging occurs. Dental professionals as part of the health care team play an important role in cancer control by utilizing oral cancer screenings, biopsies and referrals to assure oral and mucosal lesions are properly diagnosed and for identification of premalignant lesions and appropriate needed treatment  24 (Fig 5). Along with malignancies in the oral cavity, fungal infections are common in many elderly patients. Candidiasis is a white, red, or combined oral lesion that occurs when an overgrowth of the fungal oral flora takes place  25 (Fig 6). Symptoms include discomfort at the site of occurrence, altered taste, halitosis, and a decrease in saliva. Review of health histories and clinical signs obtained from the professional are the common ways of diagnosis. Medications used to treat candidiasis can be topical or systemic agents. In most cases, therapy is initiated with topical medications. However, severe disease, esophageal involvement, immunosuppression, or inadequate response to topical medications may warrant systemic therapy. The following treatment recommendations are adapted from the Clinical Practice Guideline for the Management of Candidiasis from the Infectious Diseases Society of America (IDSA).  25 OROPHARYNGEAL TREATMENT IS AS FOLLOWS:  • Mild: Nystatin suspension four times a day for 1–2 weeks, or 10 mg clotrimazole troche five times a day for 1–2 weeks  • Moderate to severe: 100-200 mg oral daily fluconazole for 1–2 weeks  • Refractory to fluconazole: 200 mg itraconazole solution once a day for up to 4 weeks  • HIV patients: Antiretroviral therapy strongly recommended  • Dentures: Disinfect dentures along with antifungal therapy  • Chlorhexidine oral rinses may be of some benefit in the control of oral candidiasis, as may some essential oils  25 Discerning and observant dental professionals can arrive at an accurate overall health assessment based on the oral status of theelder they areexamining. Oral changes observed can inform many circumstances in life confronted by that individual. Often, when I am treating the frail elderly, a song by John Prine, entitled “ Hello In There ” comes to mind. The last verse of this song has these words: So if you're walking down the street sometime and spot some hollow ancient eyes, please don't just pass 'em by and stare as if you didn't care, say, "Hello in there, hello."  26 It has been said that the greatest failure in modern dentistry is the failure to treat.  4 At the same time that dentistry is able to provide implants, esthetic veneers, and other “high-tech” treatments that would have been unimaginable only a few years ago, large segments of the population, continues on next page  Fig 5—Squamous cell carcinoma in a patient wearing a mandibular denture unaware of the condition that had progressed under the denture prosthesis. (Photograph courtesy of Stephen Wagner, DDS, FACP) Fig 6—Oral candidiasis. Mixed leukoplakic (white) and erythematous (red) on soft palate and oral mucosa. Candidiasis present on attached gingiva and vermilion border of the lip. (Photograph by Dr. Charles Tatlock, DDS, MPH)