Benign Mucosal Lesions

Geriatric Essentials

• Pressure from dentures can cause mucosal atrophy and a range of lesions that can be erythematous, hyperplastic, ulcerative, or infected by Candida.
• The elderly are at higher risk for oral candidal infection and reactivation of varicella-zoster infection.

The elderly are more likely to develop a variety of benign oral mucosal lesions. Drugs are one common cause (see Table 104-1). Many lesions can be diagnosed by visual examination, but if they are unusual and do not resolve within 3 wk, referral to a specialist, a tissue biopsy, or both are indicated. When oral mucosal lesions are painful, topical oral analgesics may provide relief until definitive treatment is given. Options include diphenhydramine elixir 12.5 mg/5 mL or 2% viscous lidocaine 5 mL combined 1:1 with 5 mL sucralfate, 5-min rinse without swallowing prn up to tid. An OTC antacid, or attapulgite, can be substituted for sucralfate. These mixtures can be applied with a cotton-tipped applicator directly to well-delineated intraoral ulcerations. To minimize symptoms and clarify an etiology pending a diagnosis, patients should be advised to stop using mouth rinses and chewing gums and to stop consuming spicy or irritating foods, alcoholic beverages, very hot fluids, and mints/lozenges.

Age-related changes: Atrophy of the oral mucosal epithelium occurs with aging but may be attributable more to extrinsic factors (eg, dentures) or disorders (eg, vitamin B₁₂/folate deficiency) common with aging rather than to age itself. The oral mucosa may be more vulnerable to local irritation as a result of the atrophy, but structure and function are usually well maintained into old age. Age-related changes that are not clinically significant include varicosities in the floor of the mouth (see Photo 104-7), ventral surface of the tongue, and hypopharynx; ectopic sebaceous glands (Fordyce's granules); and mucoceles (see Photo 104-8), cavities filled with mucous saliva and lined by epithelium or surrounded by connective tissue.

Denture-induced changes: Dentures (or other dental prostheses) can cause mucosal atrophy. Mechanical pressure from dentures can also cause lesions, which may be erythematous, hyperplastic (epulis fissuratum, which is a hyperemic lesion; see Photo 104-9), and hyperkeratotic (keratin-based, whitish lesion; see Photo 104-10), or ulcerative; generalized stomatitis, characterized by mucosal erythema, ulceration, and a pseudomembrane; or angular cheilitis (see Photo 104-16). Denture-induced stomatitis and cheilitis probably result from candidal infection in denture plaque (see Photo 104-12). Treatment may initially include topical analgesics for painful lesions; antifungals; and, for epulis fissuratum, excision of the hyperplastic lesion. All patients with these conditions should be referred to a dentist for repair or replacement of the denture or prosthesis.

Aphthous ulcers: Aphthous ulcers are round, shallow ulcers that appear on mucosal tissues not bound to bone and are typically well circumscribed with white-grayish halos (see Photo 104-13). They may occur individually and sporadically or in a syndrome of recurrent aphthous stomatitis. Cause is unknown, but individual lesions often develop in otherwise healthy people during periods of emotional or physiologic stress. Treatment is with topical or, in severe cases, intralesional corticosteroids (eg, triamcinolone 0.025% or clobetasol propionate 0.05% in orabase paste).

Systemic disorders: Systemic disorders with oral manifestations in the elderly include pemphigus vulgaris, bullous and cicatricial pemphigoid, lichen planus, Behcet's disease, erythema multiforme, and Stevens-Johnson syndrome. These are more common among middle-aged and elderly people than among younger people.

Infections: The elderly are at greater risk for oral lesions from candidal infection and reactivation of varicella-zoster infection.

Candidal infections are most common because of the increased prevalence of salivary gland dysfunction, use of removable prostheses, drugs that alter oral flora or immune function (eg, antibiotics, antineoplastics, corticosteroids, immunosuppressants), diabetes mellitus, malnutrition, and other immunocompromising conditions. Oral mucosal candidal infections may take the form of acute pseudomembranous candidiasis (thrush), characterized by white plaques or patches that may cause pinpoint bleeding when scraped away (see Photo 104-14); hyperplastic candidiasis, characterized by confluent leukoplakic plaques that cannot be scraped away (see Photo 104-15); angular cheilitis, characterized by leukoplakic and erosive lesions at the lip commissures (see Photo 104-16); or atrophic candidiasis, characterized by painful erythematous mucosal lesions, frequently located beneath dentures (see Photo 104-17). Diagnosis is suspected by appearance and confirmed by culture, smear, or biopsy. The presence of candidal hyphae in oral smears (see Photo 104-18) indicates that the oral mucosal barrier has been breached and that the patient is at risk of systemic infection. Treatment is with topical antifungal drugs (eg, nystatin oral suspension [100,000 U/mL] 5 mL qid, swished for 5 minutes and swallowed, or clotrimazole troches 10 mg qid, both given for 10 to 14 days). Nystatin-triamcinolone acetonide ointment is an effective alternative for angular cheilitis. Dentures should be kept out of the mouth for as long as possible during treatment; they should be cleaned and soaked for 10 min in a solution containing benzoic acid, 0.12% chlorhexidine, or 1% Na hypochlorite, then rinsed thoroughly. Patients who prove refractory to topical therapy may require systemic drugs (eg, ketoconazole 200 mg once/day; fluconazole 200 mg immediately, then 100 mg once/day; itraconazole 200 mg once/day) for 10 to 20 days; these drugs inhibit cytochrome P450 activity. Dose adjustment may be necessary for patients with liver disease or when taken with other cytochrome P inhibitors or inducers.

Oral zoster (eg, varicella-zoster virus, herpes zoster, shingles) is caused by reactivation of latent varicella-zoster virus present since an original infection (eg, chicken pox). Precipitating factors include thermal, inflammatory, radiologic, or mechanical trauma; immunocompromising states including cancer, lymphoma, and Hodgkin lymphoma; and systemic physiologic or emotional stress. Because these conditions are more prevalent in the elderly, herpes zoster is likely to affect them. Appearance is characterized by a painful segmental eruption of small vesicles that rupture to form confluent ulcers. Vesicles appear on skin and oral mucous membranes and occur unilaterally along ophthalmic, maxillary, or mandibular divisions of the trigeminal nerve. Ophthalmic division involvement requires close monitoring by an ophthalmologist. Postherpetic neuralgia can last for months after eruption of vesicles and causes considerable pain and neuralgia. Primary treatment is antiviral drugs (eg, valacyclovir 1000 mg tid for 7 days, famciclovir 500 mg tid for 7 days, or acyclovir 800 mg qid for 10 days). Secondary treatment for severe cases and for postherpetic neuralgia is prednisone (40 mg/day starting dose, tapered and then stopped over 10 to 14 days). Tricyclic antidepressants (eg, nortriptyline [10 mg/day starting dose, increased weekly by 10 mg to maximum dose of 50 mg bid] and gabapentin [300 mg/day on day 1, 300 mg bid on day 2, 300 mg tid on day 3 and maintained]) may also be indicated for postherpetic neuralgia.

Other: Radiation therapy to the head and neck causes stomatotoxicity and mucositis directly; other disorders (eg, Sjögren's syndrome) cause salivary gland hypofunction, which leads to mucosal disorders. Certain endocrinopathies (eg, diabetes, hypothyroidism) and nutritional deficiencies (eg, iron deficiency or pernicious anemia) can also adversely affect the oral mucosa.

This topic was last updated September 2005.