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Palliative Medicine (SB) > 10.4 (8.5) Oral Care > Flashcards

10.4 (8.5) Oral Care Flashcards

1
Q

Oral symptoms are prevalent in patients with life-limiting illnesses.

List 3 reasons this symptom may be underappreciated and undertreated.

A
  1. Inadequate oral ASSESSMENT
  2. PROVIDER perception that oral symptoms are unimportant
  3. PATIENT perception that other symptoms are more important
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2
Q

List 5 broad categories of the etiologies of oral symptoms*

A
  1. Direct (anatomical) effect of primary disease
  2. Indirect (physiological) effect of primary disease
    (i.e. fatigue , unable to do oral hygiene)
  3. Treatment of the primary disease
  4. Direct/indirect effect of coexisting disease
    (i.e. depression - less motivation for oral hygiene)
  5. Treatment of the coexisting disease
    (i.e. anti-depressant)
  6. Combination of above factors

FS:
Primary disease - direct + indirect
Primary disease Tx
Co-existing disease - direct + indirect
Co-existing disease Tx
Combo

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3
Q

List 5 common oral symptoms in patients with advanced illness.

A

Table 10.4.1:

  • Dry mouth
  • Taste disturbance
  • Coating of tongue
  • Lip discomfort
  • “Dirty mouth”
  • Difficulty swallowing
  • Cracking of lips
  • Oral discomfort
  • Difficulty speaking
  • Cracking of mouth corners
  • Difficulty chewing
  • Sensitive teeth
  • Oral ulcers
  • Bad breath
  • Jagged/sharp teeth
  • Altered sensation in mouth
  • Denture fitting problems
  • Toothache
  • Burning sensation in mouth
  • Oral bleeding

FS (5):
Lips - dry, cracking
Tongue - thrush, taste change
Teeth - denture issues, tooth ache/sensitivity, gum inflammation
Mucosa - ulcer, dry, bleeding
Throat - halitosis, dysphagia, odynophagia

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4
Q

What are three oral symptoms rated as most severe/distressing in those with advanced cancer?

A

Dry mouth
Difficulty swallowing (dysphagia)
Difficultly speaking (table 10.4.2)

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5
Q

List 3 medical consequences of oral pathology

A
  1. Generalized deterioration in physical and functional state
  2. Indirect cause of mortality (i.e. oral colonization/infection –> systemic infection)
  3. Increase complications associated with anti-cancer treatment
    i.e. oral mucositis from XRT
    i.e. osteonecrosis of jaw from bisphosphonates
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6
Q

List 3 scenarios in which a patient may need thorough assessment by a dental professional before commencing treatment

A
  1. Head and neck radiotherapy
  2. Bone marrow transplantation
  3. Bisphosphonates or denosumab

FS:
BMT -> chemo/rads can cause severe mucositis +/- GVHD causing vomiting and diarrhea

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7
Q

List 4 overarching treatment goals of oral problems

A
  1. Definitive treatment “cure”
  2. Manage cause of the problem
  3. Manage symptoms “palliative”
  4. Manage complications of the problem
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8
Q

List 3 key members of the broader multidisciplinary team for management of oral problems

A
  1. Dental professionals
  2. Speech language therapists
  3. Dieticians
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9
Q

A patient with advanced illness asks you if they should be brushing their teeth. List three things you would tell them.

A

Yes - toothbrushing is the single most important hygiene measure.

  1. Change toothbrush q3months
    or sooner if receiving chemo/immunosuppressed

Choice of toothbrush:
- in general, suggest small headed, soft-medium*
- ultrasoft if sore mouth
- powered are better for plaque than manual

  1. Brush twice per day minimum*
  2. If oral infection replace toothbrush immediately
  3. Use toothpaste with 1000ppm fluoride
  4. Non-foaming toothpaste for pts at risk of obstruction
  5. If oral discomfort with toothpaste, brush with water instead*
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10
Q

Interdental aids help remove plaque from areas between teeth that can’t be reached by toothbrush.

Ideally interdental cleaning should be done daily but may not be achievable/appropriate for some patients.

List 4 types of interdental aids.

A
  1. Dental floss
  2. Dental tape
  3. Wood sticks
  4. Interdental brushes
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11
Q

For some patients, mechanical control of dental plaque is difficult because of debilitation or oral pathology.

What is the most effective method of chemical plaque control?

2 side effects?

A

chlorhexidine

  • mouthwash/gel/spray
  • no more than twice a day
  • maintains antimicrobial activity
  • does NOT remove established plaque (need manual removal by dental professional)
  • side effects:
    staining of teeth and tongue
    mucosal discomfort from ETOH content
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12
Q

A patient has dentures. What 4 things would tell them about caring for their dentures

A
  1. Clean dentures outside mouth once per day (brush with denture cleaner)*
  2. Clean mouth and dentures separately*
  3. After every meal -> rinse denture + check mouth for food debris -> re-insert*
  4. Leave outside at night in cleaning solution*
  5. To disinfect (and prevent denture stomatitis):
    -soak plastic dentures with sodium hypochlorite
    -soak metal dentures with chlorhexidine
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13
Q
  1. Define Halitosis
  2. List 3 major categories of halitosis
A
  1. offensive odours from the mouth or hollow cavities (nose, sinuses, pharynx)

i) GENUINE halitosis (malodour present)
- organic - can be physiological OR pathological

ii) PSEUDO-halitosis (no malodor)
- non-organic disorder - responds to education

iii) HALITOPHOBIA (no malodour)
- non-organic disorder - needs psych assessment

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14
Q

Genuine halitosis: Define physiological vs. pathological halitosis (and explain general cause)

A
  1. Physiological:
    - no underlying condition causing malodour
    - most common type, even in pall care setting
    - due to bacterial putrefaction of food, cells, etc
  2. Pathological:
    - underlying disease causing malodour (malignancy, infection, inflammation)
    - oral or extra oral
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15
Q

Pathological halitosis (i.e. underlying condition present) can be categorized into 2 types of causes:
i) ORAL (90%)
ii) EXTRAORAL

List 4 categories of EXTRAORAL CAUSES.

A
  1. Diseases of upper respiratory tract
  2. Diseases of lower respiratory tract
  3. Disease of GI tract
  4. Systemic metabolic problems (renal/liver impairment, malnutrition, diabetic ketoacidosis)
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16
Q

List 2 consequences of halitosis

A
  1. May develop olfactory disturbance (unaware of halitosis) or tolerance to malodour (habituation) or taste disturbance
  2. Symptom relating to underlying cause of hallitosis
  3. Profound psychological and social effects (isolation from/by family, friends, HCPs)*
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17
Q

How can physical exam distinguish etiology of halitosis?

A
  1. If air expired from nose more offensive than breath from mouth –> nose/sinus source (upper resp)
  2. If breath from nose as offensive as from mouth –> lower resp, GI, systemic metabolic source
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18
Q

What are the treatment interventions for the 3 types of halitosis?

Name 4 strategies for genuine, physiological halitosis

A
  1. GENUINE halitosis:

i) Physiological:
- avoid offending foods*
- avoid alcohol/smoking*
- oral hygiene:*
i.e. reduce bacterial numbers/substrates + reduce volatile sulphur compounds to non-volatile via: toothpastes, baking soda, periodontal Rx, tongue cleaning, chlorhexedine, mouthwashes

  • masking agents:*
    i.e. mints, chewing gums, mouthwashes

ii) Pathological:
- treat underlying disease process

  1. PSEUDO-halitosis
    - educational interventions

iii) HALITOPHOBIA
- do NOT respond to education
- need psychological/psychiatric Rx

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19
Q
  1. Define salivary gland dysfunction (SGD)
  2. Define Xerostomia
  3. Define salivary gland hypofunction
A
  1. SGD: Any change in the QUALiTY or QUANTITY output of saliva caused by hyperfunction or hypofunction in salivary output
  2. Xerostomia: SUBJECTIVE sensation of dry mouth
  3. SGH: Objective reduction in either whole or individual gland flow rates

** Xerostomia can be from decrease volume of saliva (SG hypofunction) but may also be from change in composition of saliva

20
Q

The prevalence of xerostomia (78-82%) and salivary gland hypofunction (82-83%) is high in patients with advanced cancer.

List 4 causes of xerostomia (or “SGD” per 6th edition)

A 
medication related (tx and palliative - analgesics, antiemetics etc)
cancer related (ie. tumor infiltration, paraneo)
xrt
dehydration
malnutrition
anxiety
depression

FS: DIMS-O
Drugs - antichonergic, rads
Infection
Metabolic - dehydration, malnutrition
Structural - cancer
Other - depression, anxiety

21
Q

List six complications of xerostomia (“SGD” per 6th edition)

A

See pg 660

  1. General problems - oral discomfort, lip discomfort
  2. Eating related problems - anorexia, taste disturbance, difficulty chewing/swallowing, decreased intake
  3. Speech related problems
  4. oral hygiene - poor, halitosis
  5. Oral infections - candidiasis, dental carries, peridontal disease, salivary gland infections
  6. systemic infections - secondary to oral infection
  7. dental/dental prosthesis problems - dental erosion
  8. psychosocial problems - embarassment, anxiety, depression, isolation
  9. Misc - sleep disturbance, difficultly with oral/transmucosal meds, esophagitis, urinary frequency due to increased fluid intake

FS: think 6 oral issues in general
Lips - lip discomfort
Teeth - dental erosion, carries
Tongue - candidiases, taste disturbance
Mucosa - mucositis, esophagitis
Throat - trouble swallowing/anorexia, trouble speaking, halitosis

22
Q
  1. 3 signs of salivary gland hypofunction on physical exam.
  2. What discrepancy is important to note in patients with xerostomia?
A
  1. Signs:
    - lips - dry, cracking
    - tongue - fissuring
    - mucosa - dry, absent of saliva pool on the floor of mouth
  2. Patients with xerostomia (and some with SGH) may have no obvious abnormalities on exam
23
Q

Treatment of SGD - Symptom treatment:

What is the difference between saliva stimulants and saliva substitues.

List 2 examples of each.

Why would you prescribe one over
the other?

A
  1. Saliva stimulants
    - promote secretion of “normal saliva” so ameliorate xerostomia AND other features of SGD

Examples:
-gum*
-organic acids (ie. ascorbic, citric, malic acid)
-parasympathmomimetic drugs:
e.g. cholinesters - pilocarpine*
e.g. cholinesterase inhibitors - pyridostigmine
-acupuncture

  1. Saliva substitute (agents that replace missing saliva)
    - physically/chemically different from normal saliva so only ameliorate xerostomia

Examples:
water
artificial saliva

*Studies show patients prefer stimulant.
**Some patients may not respond and need substitutes (i.e. XRT induced SGD)

24
Q
  1. What is the difference between sialorrhea vs. drooling
  2. Does a patient with drooling necessarily have sialorrhea?
A
  1. Sialorrhea is an excessive secretion of saliva
    Drooling is abnormal spillage of saliva from mouth
  2. Drooling is usually not related to sialorrhea
    Many patients have salivary gland hypofunction rather than sialorrhea
25
Q

List two broad mechanisms that lead to drooling

A
  1. Difficulty retaining salvia in mouth (facial weakness)
  2. Difficulty removing saliva from mouth (dysphagia)
26
Q

List four drooling treatments (2 meds, 2 interventions)

A

anticholingeric drugs (glyco, scopolamine)
botulinum toxin A
parasympathetic nerve ablation
salivary duct relocation

27
Q

List four approaches to manage thick, tenacious saliva

A 
Treat source:
Treatment of SGD (xerostomia)* 

Treat symptom:
Hydration *
Humidification*
Oral rinsing (soda water, sodium bicarb)*
dietary manipulation (ie avoidance of caffeine)
28
Q

List 3 types of taste disturbance

A

Hypogeusia - reduced taste sensation
Ageusia -absence of taste
Dysgeusia - distortion of normal taste sensation

FS: absent, reduced, change

(Patients may have a single taste problem or a combination of taste prob

29
Q

List six causes of dysgeusia

A

Cancer related - damage to taste buds, CNs, CNS

cancer tx related - chemo/sx/xrt

oral problems - SGD, poor hygiene, oral infection

neuro problems - damage to CNs, damage to CNS

metabolic problems - malnutrition, zinc deficiency, renal dysfunction

misc - aging, menopause, COVID

FS
Vascular - dehydration
Infection - COVID, thrush
Neoplastic
Degenerative - renal
Iatrogenic - chemo, rads
Endo - aging, menopause
Neuro - CNS damage

30
Q

List three dietary interventions for patients with dysgeusia

A
  1. Eat food that tastes good*
  2. avoid food that tastes bad*
  3. Zinc supplementation
  4. enhancing food that tastes good (ie. add salt, sugar)*
  5. modify temperature, consistency, presentation of food
31
Q

List four risk factors for candida colonization

A

Patients with SGD
Dentures (upper)

Use of topical antibiotics
Use of topical steroids

32
Q

List 4 manifestations of oral candidosis - which is the most common?

A
  1. Pseudomembranous candidosis (most common type)
  2. Erythematous candidosis
  3. Denture stomatitis
  4. Angular cheilitis

PEDA

33
Q

List 2 complications of oral candidosis

A
  1. Esophageal candidosis (odynophagia + dysphagia) - frequent
  2. Candidemia - less frequent
34
Q

How is a diagnosis of oral candidosis made?

List 2 reasons this is challenging

A
  1. Combo of clinical features + microbi investigations. (Diagnosis should be made if heavy growth on swabs)
  2. i) non-specific clinical features
    ii) patients may be yeast carriers
35
Q

List 3 important considerations in limiting drug resistance when prescribing anti-fungals for oral candidosis

A
  1. Only prescribe for microbiologically proven cases of oral candidosis
  2. Prescribe for shorter durations (longer promotes resistance)
  3. Prescribe in high doses (lower doses promote resistance)
36
Q

What are 2 reasons for recurrent episodes of oral candidosis despite treating infection

A
  1. Underlying cause was not treated (i.e. treating SGD reduces recurrence)
  2. Lack of denture hygiene/disinfection
37
Q

List five drugs (3 main drug classes) that are used in palliative care that may interact with fluconazole.

Through what enzyme and mechanism does the interaction take place.

A

Fluconazole = CYP 450 3A4 inhibitor

Methadone
ondansetron
haloperidol
quetiapine
dexamethasone
domperidone
citalopram
mirtazapine
trazodone
Fentanyl 
methotrimeprazine

FS: substrates - O BAD
Opioids: TOM-F
Benzo
Antipsychotic: haldol, quetiapine, nozinan
Dex

38
Q

List 3 topical antifungal agents for managing oral candidosis

A

Table 10.4.3:

  1. Polyene group - nystatin, amphotericin B
  2. Azole - miconazole, clotrimazole
  3. Other: chlorhexidine, gentian violet, tea tree oil

FS: CAN - clorhexidine, azole, nystatin

39
Q
  1. List 3 reasons you should consider systemic rather than topical antifungal agents for oral candidosis?
  2. List 2 systemic antifungals
A
  1. Generalized infection
    Persistent/recurrent infection
    Infections in immune-suppressed patient

Fluconazole - 1st line

Itraconazole - for fluconazole resistant/refractory disease

Variconazole - refractory disease

FS: FIV

40
Q
  1. Which virus causes primary herpetic gingivostomatitis (the most common viral infection of the mouth)?
  2. How do herpes viruses establish latent infections?
  3. What is the presentation of reactivation in immunocompetent vs immunosuppressed patients?
A
  1. Mostly HSV type 1
  2. HSV lies dormant in trigeminal ganglion
  3. IC = herpes labialis (cold sore)
    IS = oral lesions, painful, crops of ulcers or florid, need lab testing to confirm diagnosis)
41
Q

What is the HSV treatment approach for:
- Immunocompetent patients
- Immunosuppressed patients

Name 2 antiviral meds

A

Table 10.4.5:

Immunocompetent - herpes labialis
- Topical acyclovir x 5-10 days

Immunosuppressed - herpes labialis/oral ulcer
- Oral acyclovir x 5 days min
- IV antiviral if severe

Famcyclovir and Valacyclovir are alternatives

42
Q
  1. Define oral mucositis vs oral stomatitis
  2. Where does pain originate in oral mucositis?
A
  1. Oral mucositis is mucosal inflammation secondary to cancer treatment
    VERSUS
    Oral stomatitis is mucosal inflammation from other causes (infection/trauma)
  2. Inflammation of the oral SUBmucosa (as opposed to ulceration of the mucosa)
43
Q
  1. Which parts of the mouth are affected the most by oral mucositis?
  2. What are the 3 stages of oral mucositis?
  3. What is the most consistent symptom of oral mucositis?
  4. List 4 complications of oral mucositis
  5. What is the natural history of oral mucositis after chemo, rads, vs other source
A
  1. Non-keratinized surfaces affected most severely (mucosa of lips, cheeks, floor of mouth)
  2. Mucosa appears red —> white (desquamation) —> ulcerates (and exudative pseudomembrane forms)
  3. Pain - constant, aggravated by eating, drinking, oral hygiene. Severity of pain correlated with severity of mucositis. Some patients need opioids
  4. Dehydration
    malnutrition
    infection (local or systemic)
    local hemorrhage
    interference with cancer treatment
  5. Self-limiting condition with recovery:
    - 2 weeks after chemotherapy
    - 3-4 weeks after XRT
    - variable - some patients can have more chronic sx
44
Q

List 3 non-medical and 3 medical treatment options for oral mucositis

What is the evidence for topical anesthetic and sulcrate?

A
  1. Management

Non medical:
- mouth care / oral hygiene - bland mouthwash
- hydration
- nutrition

Medical:
- opioid* - opioid analgesics
- benzydamine mouthwash* (NSAID) - non opioid analgesic
- topical doxepin (TCA)*, topical lidocaine
- oral cryotherapy - adjuvant analgesic
- recombinant human keratinocyte GF
- systemic zinc supplments
- low level laser therapy

  1. little/no evidence for topical anaesthetics or coating agents and sulcralfate mouthwash should not be used
45
Q

What are 3 important points of education for family/HCPs providing oral care in the terminal phase?

A
  1. FREQUENCY of oral care should be individualized to patient need, not protocol based
  2. FAMILIES should be given the option to provide (with support) or opt out of oral care for their loved one
  3. Dry oral mucosa unlikely to be source of distress in unconscious PATIENT. But water-based moisturizing gel may be more effective than water

Palliative Medicine (SB) (145 decks)

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