JOURNAL READING

COMPREHENSIVE MANAGEMENT OF ORAL FRAILTY IN MULTIPLE

SYSTEMIC DISEASE GERIATRIC PATIENT (CASE REPORT)

BY:
NUR FAUZIANA HAYUNINGTYAS 160112200501
MARLYANA FAUZIA 160112220025
KHANSA AISYI RAHMAH 160112220026
BLANDINA TSANARAYYA AMARANTHA 160112220027
AMIRA ALIYA NURHADIATI HUSEIN 160112220028

SUPERVISOR:

DEWI ZAKIAWATI, drg., M.Sc., Sp.PM

DEPARTMENT OF ORAL MEDICINE

FACULTY OF DENTISTRY
UNIVERSITAS PADJADJARAN
BANDUNG
2023

1
 TABLE OF CONTENT

TABLE OF CONTENT ............................................................................................................. i

TABLE OF FIGURE ................................................................................................................ ii
TABLE OF TABLES .............................................................................................................. iii
JOURNAL’S VALIDITY ......................................................................................................... 1
METHODS ............................................................................................................................... 1
CONTENT ................................................................................................................................ 3
DISCUSSION ......................................................................................................................... 11
CONCLUSION ....................................................................................................................... 17
REFERENCE ................................................................................................................ 18

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 TABLE OF FIGURE

Figure 1. Dentino: Jurnal Kedokteran Gigi profile on SINTA ................................................ 1

Figure 2. Total of Google Citation, h-Index and i10-index ..................................................... 2
Figure 3. CiteScore Rating of Dentino: Jurnal Kedokteran Gigi ............................................. 3
Figure 4. The hierarchy of evidence based medicine.6............................................................. 1
Figure 5. Structure of Case Report ........................................................................................... 2
Figure 6. Clinical features of the initial visit............................................................................ 4
Figure 7. Two days of follow ................................................................................................... 7
Figure 8. Seven days of follow ................................................................................................ 8
Figure 9. Ten days follow up ................................................................................................... 9
Figure 10. Fourteen days follow up ......................................................................................... 9

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 TABLE OF TABLES

Table 1. Challacombe scale of the patient ................................................................................ 5

Table 2. Laboratory results....................................................................................................... 6
Table 3. D-E-N-T-A-L Questionnaire .................................................................................... 15

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 JOURNAL’S VALIDITY

Dentino: Jurnal Kedokteran Gigi is a dental journal managed by the Faculty of

Dentistry, Lambung Mangkurat University, Indonesia. This journal contains of
research articles within the field of Restorative Dentistry. This journal has been
accepting and publishing research papers that aims to influence the practice of dentistry
not only at clinician but also research, industry and policy level on an international
basis.
Dentino has been accredited as SINTA 3 journal. Published twice a year every
March and September, this journal provides open access to its content and articles
making research freely available to the public. Thus, the chance of getting a greater
exchange of knowledge has been provided.

Figure 1. Dentino: Jurnal Kedokteran Gigi profile on SINTA

1
 Based on the SINTA profile, Dentino has been accredited as SINTA 3 journal
in 2016, but falls in the SINTA 6 in 2018. The journal then improved and was
accredited back as SINTA 3 in 2019 until now. The citation per year by google scholar
has been increasing. As per 2023, Dentino has been cited over 1337 times by Google
Scholar.

Figure 2. Total of Google Citation, h-Index and i10-index

Dentino: Jurnal Kedokteran Gigi hasn’t yet indexed in Scopus which shows that
the journal has not been evaluated by Scopus for inclusion in its database. This also
leads to the fact that the quality and impact of their content as International Journal has
not been evaluated. There are no CiteScore and CiteScore Rankings for this journal and
the SCImago Journal Rank can’t identify this journal. This journal only has the i10-
index which has been promoted by Google Scholar. The i10-index is defined as the
number of publications with greater than 10 citations, and the h-index is an author-level
metric that measures both the productivity and citation impact of the publications.
Hence, this journal reputation is only assessed by SINTA and has not been accepted on
the Scopus database.

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Figure 3. CiteScore Rating of Dentino: Jurnal Kedokteran Gigi

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 BACKGROUND

The age of elderly is the age that a human’s body becomes more susceptible to
exposure to any kind of disease. The World Health Organization classified the elderly
as individuals who have entered over 60 years old. The proportion of older adults in
the population will steadily increase, shown by data from The World Health
Organization in 2018 that stated that nearly 434 million people will be 80 years and
older by 2050. Aging could lead to health problems, care dependency and an elevated
frailty risk 1. Various pathological conditions due to metabolic changes due to age
2,3
coexisting with systemic disease becomes a serious public health problem . Those
also affect oral mucosa which is shown as a manifestation. Oral mucosal lesions such
as infections, neoplasms, xerostomia, hematological disorders and other kind of
systemic disease manifestation could happen easily on elderly which shows their oral
vulnerability, also referred to as oral frailty 1.
Frailty is a biological syndrome associated with a decline in physical status and
activities, and increased vulnerability to adverse health outcomes 4. Gobbens et al. also
explains that frailty is a dynamic state affecting an individual who experiences losses
in one or more domains of human functioning (could be physical, psychological,
social) that are caused by the influence of a range of variables and which increases the
risk of adverse outcomes. Clegg et al. illustrate this risk in their review by explaining
that a seemingly minor event (new drug, minor infection or minor surgery) can lead to
a disproportionate change in health status, potentially transforming an older person
from independent to dependent. These frailty and care dependency are often
accompanied by a higher need for oral hygiene support because many dependent older
1,4
adults have difficulty taking care of their mouth . Oral cavity has several essential
functions that affect quality of life. Therefore, oral health is an essential aspect of
health. Impairment of oral functions is very common in older individuals and this

4
adverse feature of aging can indirectly interact with several frailty domains through
multiple pathways 3,5.
Poor oral health among the elderly is an important issue in general health due
to pathogenesis of frailty. In gerodontology research, there is a strong emphasis on
measuring and reporting the oral health of older adults and its relationship to general
health. On recent research, it has been suggested that oral frailty should be considered
a geriatric syndrome and screened regularly for older person 3,4. The major causes are
poor dental status and sarcopenia. Some of the oral frailty conditions require
appropriate treatments. It is therefore important to develop an effective early
prevention method with a view to delaying new onsets of physical frailty including oral
frailty. The aim of this case report is to describe the comprehensive management of
oral frailty in a medically compromised geriatric patient prior to cardiovascular
surgery.

5
 METHODS

“The best teaching of medicine is that taught by the patient himself”, a quote
said by William Osler, a Canadian physician and founding professor of the Johns
Hopkins Hospital. This article comes in the form of case report, which data is based on
the symptoms the patient exhibited. Case report is one of research designs where an
unforeseen or novel circumstance is thoroughly described in a detailed report of
finding, clinical course, and prognosis of an individual patient, assisted or backed by
review of literature of other reported cases.6
According to the hierarchy of evidence-based practice, case reports are
considered as the lowest in medical literature. It provides vital information for
unfamiliar events and shared individual experiences, for improved understanding and
optimizing patient care, which may lead to a hypothesis, but yet to be confirmed
through confirmatory quantitative experimental or observational study designs such as
clinical trials or cohort studies.6

Figure 4. The hierarchy of evidence based medicine.6

Case reports should be short and focused, with a limited number of figures and
references. There are usually a restricted number of authors. The structure of a case
report usually comprises a short unstructured (or no) abstract, brief (or no) introduction,
report of the case, and discussion. Unlike original articles, case reports do not follow
the standard IMRAD structure of the manuscript organization. As there is a wide
variation in the format for case reports among different journals, it is essential for
authors to follow exactly the target journal’s Instructions to Authors.6

Figure 5. Structure of Case Report

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 CONTENT

In this current case report, we present a 64-year-old male with comprehensive

of oral frailty in a medically compromised prior to cardiovascular surgery.
A 64-year-old male was referred to the Oral Medicine Department from the
Cardiovascular Department Dr. Hasan Sadikin General Hospital Bandung with chief
complaints of pain in swallowing, dry, and sore mouth since two days ago. There was
no history of recurrent sore mouth. He had not brushed his teeth for three days because
of these complaints and did not regularly check up with the dentist. He had lost 12 kg
in the past month because of inadequate intake due to loss of appetite. He was a heavy
smoker since 57 years ago (more than 40 cigarettes/day). The history of alcohol
consumption and drug abuse was denied. The patient was currently on fluid restriction
from Cardiology Department.
He was hospitalized due to shortness of breath and currently diagnosed with
infective endocarditis (IE). He was also diagnosed with other systemic diseases
including acute kidney injury (AKI), thrombocytopenia related to IE aggravated by
drugs (furosemide), hyponatremia et causa hemodilution, hypocalcemia et
hypokalemia (hypomagnesia) et causa renal loss(furosemide), respiratory failure and
electrolyte-fluid imbalance. His contributory past medical history was uncontrolled
type II diabetes mellitus (DM) for five years. During hospitalization, he received
furosemide, digoxin, captopril, calcium gluconate, gentamycin, ampicillin-sulbactam,
potassium chloride, calcium carbonate, lansoprazole, paracetamol, magnesium sulfate,
bisoprolol, ramipril and lactulose.
Extra-oral examination revealed lymphadenitis on the right submandibular
lymph node, icteric sclera, dry exfoliative lips and dry saliva at both corners of the lips.
Intra-oral examination (Figure 6) showed poor oral hygiene. There were plaque, stains,
calculus, caries, retained root tips and missing teeth. The gingiva showed multiple,
diffuse, blackish-brown macules along the anterior upper and lower attached gingiva.
Dorsum of the tongue was depapilated with debris accumulation on it. Frothy saliva

3
and absent of saliva at the floor of mouth. The overall oral mucosa looked dry, mouth
mirror sticking to the tongue and buccal mucosa. The scraped off white plaque leaving
erythematous area was found on the dorsal and ventral tongue, buccal mucosa, and
hard palate. Irregular multiple major ulcers, surrounded by erythema, well-demarcated
with yellowish concave base and covered by thick yellowish-green sputum at the soft
palate to the uvula.

Figure 6. Clinical features of the initial visit

The subjective examination of xerostomia was carried out using a dry mouth
questionnaire introduced by Thomson et al. The result was xerostomia with 31
cumulative points. The objective examination of xerostomia was carried out using the
Challacombe scale (Table 1) and showed moderate xerostomia with six points. The

4
laboratory investigations showed in table 2. The patient was also tested with anti-CMV
IgM and IgG to rule out the possibility of cytomegalovirus infection. The diagnosis for
this patient were exfoliative cheilitis, acute pseudomembranous candidiasis, aphthous-
like ulcer, moderate xerostomia and smoker’s melanosis.

Table 1. Challacombe scale of the patient

5
 Table 2. Laboratory results

The acute pseudomembranous candidiasis and aphthous-like ulcer were treated

with 0.12% chlorhexidine digluconate mouthwash three times a day, while the
moderate xerostomia was treated with chlorine dioxide (ClO2)-zinc mouthwash three
times a day. The patient was also instructed to apply a thin layer of 100% petroleum
jelly three times a day to treat the exfoliative cheilitis. Oral hygiene instruction included

6
brushing the teeth and tongue two times a day and sipping the amount of water
according to the fluid restriction. He was also advised to do mouth preparation prior to
cardiovascular surgery.

Figure 7. Two days of follow

After two days of follow-up (Figure 7), the oral cavity looked cleaner than
before but still felt the same complaints as at the first visit. He could brush his teeth
and take topical medications routinely including 0.12% chlorhexidine digluconate 30-
60 minutes before meals, ClO2-zinc mouthwash 30-60 minutes after meals and 100%
petroleum jelly.
After seven days of follow-up (Figure 8), complaints of dry mouth persist due
to fluid restriction. The burning sensation and pain in swallowing had subsided.

7
Therefore, topical medications were still being used.

Figure 8. Seven days of follow

After the 10th and 14th days of follow-up (Figure 9 and Figure 10), almost all
the complaints disappeared. Scaling, restoration of the carious teeth and teeth
extraction had been done. He remained in fluid restriction and was scheduled to
undergo cardiovascular surgery next week. Meanwhile, he still used topical

8
medications routinely.

Figure 9. Ten days follow up

Figure 9. Ten days follow up

Figure 10. Fourteen days follow up

9
 After one month of follow-up, there were no complaints of dryness and pain in
the oral cavity. A week before the patient underwent cardiovascular surgery
successfully. There was no fluid restriction anymore and planned to be discharged from
the hospital. Furthermore, he was advised to maintain oral hygiene, eat a balanced
nutritious diet regularly, drink enough water and apply 100% petroleum jelly on his
lips.

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 DISCUSSION

Infectious endocarditis is the inflammation of the endocardium, the inner lining

of the heart, as well as the valves that separate each of the four chambers within the
heart. It is primarily a disease caused by bacteria and has a wide array of manifestations
9

and sequelae. The vast majority of infectious endocarditis cases stem from gram-
positive streptococci, staphylococci, and enterococci infection 9.
Acute kidney injury (AKI) is a clinical syndrome manifested by a rapid or
abrupt decline in kidney function and subsequent dysregulation of the body electrolytes
and volume, and abnormal retention of nitrogenous waste 5. Most patients with AKI
have no clinical symptoms related to AKI and are diagnosed on the basis of a routine
laboratory blood test 5.
Frailty is described as an identifiable state of older adults with greater
vulnerability. Older adults usually have age-related declines in physiological status
3

and various organ systems, such as decrease in the ability to cope with chronic or acute
stressor. Meanwhile, oral frailty is described as a decrease in oral function together
3

with a decline in cognitive and physical functions, such as oral microbiota and
Alzheimer’s disease neurodegeneration 7. Poor oral health is common in the elderly
population and involved in frailty, which may influence eating habits and food
preferences and impact on diet quality 3.
Type 2 Diabetes Mellitus (T2DM) accounts for around 90% of all cases of
diabetes. In T2DM, the response to insulin is diminished and defined as insulin
8

resistance. During this state, insulin is ineffective and initially countered by increased
8

insulin production to maintain glucose homeostasis, but over time, insulin production
decreases, resulting in T2DM 8. Diabetes is linked to oral and maxillofacial movement
disorders, taste disturbances, dry mouth, burning mouth syndromes and swallowing
problems 3. Dehydration caused by prolonged hyperglycemia and polyuria are
significant factors in development of xerostomia and salivary gland hypofunction in
diabetics 3.

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 Xerostomia is a subjective complaint of dry mouth, whereas hyposalivation is
an objective decreased of salivary flow.10 Xerostomia and hyposalivation are
frequently caused by dehydration, especially in elderly people with insufficient fluid
intake. Uncontrolled diabetes can lead to polyuria, which in turn causes dehydration.
Diuretics (in this case, the patient consumed furosemide), which influence the
regulation of this homeostasis, can produce xerostomia, decrease salivary flow rates
and alter the composition of saliva. Dehydration affects oral mucosal immunity by
decreasing the release of antimicrobial proteins including lysozyme and α-amylase as
well as the overall flow rate of saliva.3
Diabetes is linked to oral and maxillofacial movement disorders, taste
disturbances, dry mouth, burning mouth syndromes and swallowing problems.3 Both
types of DM, T1DM and T2DM, have been associated previously with xerostomia.
There are also studies that have showed a decreased salivary flow in DM patients in
relation to non-DM patients. The reason for these problems could be due to damage to
the gland parenchyma, alterations in the microcirculation to the salivary glands,
dehydration, and disturbances in glycemic control.10 The causes of reduced salivary
secretion in diabetic patients may be multiple. The prevalence of glycosuria caused by
mild hyperglycemia results in fluid loss and dehydration of the body, and as a
consequence, to decreased secretion of saliva.11
Xerostomia secondary to hyposalivation may also result in rampant dental
caries, oral fungal infections (eg, candidiasis), taste changes, halitosis, or burning
mouth. Xerostomia appears to increase with increasing age. A possible explanation is
that older individuals take of medications with potential xerostomic effects for their
chronic conditions and this may lead to an overall reduction of salivary flow rate.12,13
Adequate secretion of saliva is essential to maintain oral health due to the
salivary properties of lubrication, protection, pH control, antimicrobial action, and
defence. Systemic and autoimmune diseases, such as diabetes and Sjogren's syndrome,
are also associated with hyposalivation.12 Hyposalivation leads to dryness of the oral
mucosa, inefficient food bolus formation and transport, demineralisation of dentition,

12
mucosal ulceration, altered oral flora and deficiency in dental prosthesis retention,
which affects oral health and quality of life.14 The most frequent cause of
hyposalivation is the use of certain medications (such as anticoagulants,
antidepressants, antihypertensives, antiretrovirals, hypoglycemics, levothyroxine,
multivitamins and supplements, non-steroidal anti-inflammatory drugs, and steroid
inhalers).12 Angiotensin-converting enzyme (ACE) inhibitors are associated with dry
mouth, such as ramipril and captopril that the patient consumed during hospitalization.
Meanwhile, it will indirectly affect saliva by changing fluid and electrolyte balance.
He was treated with these drugs due to eliminate the proteinuria and to prevent
cardiorenal disease that can develop during his course of diseases.3,15
This patient also complained of 12 kg weight loss in one month, this possibly
caused by eating difficulty because there was taste disturbance (loss of appetite). Oral-
1
maxillofacial movement disorders mostly leads to swallowing problems. While
chronic oral mucosal pain disorders can contribute significantly to taste disturbances,
an acute condition of inflammation worsen this condition, this patient revealed to be
have oral ulceration. The condition also exacerbated by the systemic complaints and
his bad habit such as smoking. Smoking can cause a drier oral cavity, causing
discomfort when swallowing. The appearance of oral mucosal will also change over
time, both color and histological changes. Color changes in smoking patients are
caused by excess melanin deposits. While histological changes, the oral epithelium
becomes thinner, loses elasticity and atrophies with age, making it more susceptible to
pathology. This condition especially aggravated with underlying systemic diseases. 16-
18

Another condition that is also commonly found in geriatric patients is candida

infection. This is caused by a compromised immune system. Plus, the patient also has
a history of diabetes. Apart from that, it can also be caused by medication- or disease-
induced dry mouth and removable dentures. This condition considered to be most

13
vulnerable condition to developing candidiasis. Candida albicans is an opportunistic
flora that can become pathogenic due to local or systemic factors. Several systemic
conditions that cause candidiasis include diabetes, anemia and HIV, especially
immunocompromised diseases and the condition of geriatric patients with a weakened
immune system. Apart from that, another local factors are hyposalivation, wearing
dentures and taking topical steroids, antibiotics, or immunosuppressive medications.
Additionally, like a vicious cycle, additional medications administered to treat these
conditions may have negative side effects due to polypharmacy. 19
Oral ulceration is a complex and varied condition, characterized by damage or
destruction in the integrity of the oral epithelium, followed by loss of the underlying
connective tissue, resulting in a crateriform appearance. 20 Apart from being caused by
a lack of folic acid, one of the most common factors causing ulcers is trauma (traumatic
ulcers). 21,22 At the first visit, the major ulcerations were suspected as CMV oral ulcers.
Cytomegalovirus (CMV) is a genus of viruses of the order Herpesvirales, which is
estimated to infect approximately 90% of adults at some point in their lives. CMV
infection is usually subclinical and can persist in this manner for the entire life span of
an infected individual. It is also an opportunistic pathogen and can affect multiple
organs, leading to pneumonia, peptic ulcers, retinitis, and/or encephalitis in
immunocompromised hosts. Some cases also report CMV infection of the buccal
mucosa in an immunocompromised patient causes oral ulcers. Therefore, the serology
test was conducted but the result (Table 3) was negative for IgM and reactive (29,00)
for IgG. In acute CMV infection, and increase in igG and igM is generally found.
However, the link between ulcers and CMV cannot be confirmed without further
testing using Polymerase Chain Reaction (PCR). 23
Several complex conditions experienced by patients can be a source of oral
frailty. First, due to the condition of the oral cavity of geriatric patients with smoking

14
habits and several systemic conditions, the nutrition from the food obtained by the
patient is not fulfilled. According to the evidence, poor nutrition may be a serious risk
for the occurrence of frailty. Inflammation is yet another potential link between oral
health and frailty. Apart from that, inflammatory conditions in the patient's oral cavity
can also be a source of periodontal disease. Periodontitis is an inflammatory condition
in the supporting tissues of the teeth (periodontal) and if not treated, periodontitis will
be progress to cause progressive bone destruction followed by tooth loss. This also
could lead to loss of appetite and less nutrition intake.
The oral frailty screening was done for this patient using a D-E-N-T-A-L
questionnaire examination (Table 1). This questionnaire assesses the discomfort felt by
the patient and produces 7 oral frailty results.

Table 3. D-E-N-T-A-L Questionnaire

These results also make it easier for dentists to determine what treatment the
patient needs, in this patient including mouth preparation prior to cardiovascular
surgery, topical medications as pharmacological therapy, and dental health education
(oral hygiene instruction) as non-pharmacological therapy. The patient also needs
periodontal treatment such as scaling and root planning, the tooth extraction, as well as
restorations for the caring teeth were done as the mouth preparation. Mouth preparation

15
is needed before cardiovascular surgery to prevent focal infection which could worsen
the patient's condition.
Apart from that, medication was also given in the form of ClO2-zinc
mouthwash and 0.12% CHX (Chlorhexidine) mouthwash which were used 3 times a
day as well as application of 100% petroleum jelly on the lips. Zinc-acetate maintains
a moist (not dry) condition in the oral cavity. Then, ClO2 (Chlorine Dioxide) causes
the pH in the oral cavity to become normal. This causes the condition of the oral cavity
to not be good enough for the development of candida. On the other side, CHX is a
24
strong base at physiological pH . The phosphate-containing protein components of
the bacterial cell wall are adsorbed by chlorhexidine. Additionally, it acts as
bacteriostatic, bactericidal, fungicidal, fungistatic and some virus-killing properties.
Petroleum jelly (also called petrolatum), has been widely used as a moisturizer. 25 This
treatment resulted in a very significant improvement.

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 CONCLUSION

Oral frailty is very likely to occur in geriatric patients and should be a concern
because of their susceptibility to exposure to various diseases. Clinicians must be able
to carry out diagnosis and therapy carefully and precisely, and be able to understand
how to immediately refer to a specialist if necessary. So that it can prevent worsening
of the patient's condition, morbidity, and can improve the quality of life of patients.

17
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