10.4 (8.5) Oral Care Flashcards
Oral symptoms are prevalent in patients with life-limiting illnesses.
List 3 reasons this symptom may be underappreciated and undertreated.
- Inadequate oral ASSESSMENT
- PROVIDER perception that oral symptoms are unimportant
- PATIENT perception that other symptoms are more important
List 5 broad categories of the etiologies of oral symptoms*
- Direct (anatomical) effect of primary disease
- Indirect (physiological) effect of primary disease
(i.e. fatigue , unable to do oral hygiene) - Treatment of the primary disease
- Direct/indirect effect of coexisting disease
(i.e. depression - less motivation for oral hygiene) - Treatment of the coexisting disease
(i.e. anti-depressant) - Combination of above factors
FS:
Primary disease - direct + indirect
Primary disease Tx
Co-existing disease - direct + indirect
Co-existing disease Tx
Combo
List 5 common oral symptoms in patients with advanced illness.
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
What are three oral symptoms rated as most severe/distressing in those with advanced cancer?
Dry mouth
Difficulty swallowing (dysphagia)
Difficultly speaking (table 10.4.2)
List 3 medical consequences of oral pathology
- Generalized deterioration in physical and functional state
- Indirect cause of mortality (i.e. oral colonization/infection –> systemic infection)
- Increase complications associated with anti-cancer treatment
i.e. oral mucositis from XRT
i.e. osteonecrosis of jaw from bisphosphonates
List 3 scenarios in which a patient may need thorough assessment by a dental professional before commencing treatment
- Head and neck radiotherapy
- Bone marrow transplantation
- Bisphosphonates or denosumab
FS:
BMT -> chemo/rads can cause severe mucositis +/- GVHD causing vomiting and diarrhea
List 4 overarching treatment goals of oral problems
- Definitive treatment “cure”
- Manage cause of the problem
- Manage symptoms “palliative”
- Manage complications of the problem
List 3 key members of the broader multidisciplinary team for management of oral problems
- Dental professionals
- Speech language therapists
- Dieticians
A patient with advanced illness asks you if they should be brushing their teeth. List three things you would tell them.
Yes - toothbrushing is the single most important hygiene measure.
- 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
- Brush twice per day minimum*
- If oral infection replace toothbrush immediately
- Use toothpaste with 1000ppm fluoride
- Non-foaming toothpaste for pts at risk of obstruction
- If oral discomfort with toothpaste, brush with water instead*
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.
- Dental floss
- Dental tape
- Wood sticks
- Interdental brushes
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?
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
A patient has dentures. What 4 things would tell them about caring for their dentures
- Clean dentures outside mouth once per day (brush with denture cleaner)*
- Clean mouth and dentures separately*
- After every meal -> rinse denture + check mouth for food debris -> re-insert*
- Leave outside at night in cleaning solution*
- To disinfect (and prevent denture stomatitis):
-soak plastic dentures with sodium hypochlorite
-soak metal dentures with chlorhexidine
- Define Halitosis
- List 3 major categories of halitosis
- 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
Genuine halitosis: Define physiological vs. pathological halitosis (and explain general cause)
- Physiological:
- no underlying condition causing malodour
- most common type, even in pall care setting
- due to bacterial putrefaction of food, cells, etc - Pathological:
- underlying disease causing malodour (malignancy, infection, inflammation)
- oral or extra oral
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.
- Diseases of upper respiratory tract
- Diseases of lower respiratory tract
- Disease of GI tract
- Systemic metabolic problems (renal/liver impairment, malnutrition, diabetic ketoacidosis)
List 2 consequences of halitosis
- May develop olfactory disturbance (unaware of halitosis) or tolerance to malodour (habituation) or taste disturbance
- Symptom relating to underlying cause of hallitosis
- Profound psychological and social effects (isolation from/by family, friends, HCPs)*
How can physical exam distinguish etiology of halitosis?
- If air expired from nose more offensive than breath from mouth –> nose/sinus source (upper resp)
- If breath from nose as offensive as from mouth –> lower resp, GI, systemic metabolic source
What are the treatment interventions for the 3 types of halitosis?
Name 4 strategies for genuine, physiological halitosis
- 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
- PSEUDO-halitosis
- educational interventions
iii) HALITOPHOBIA
- do NOT respond to education
- need psychological/psychiatric Rx
- Define salivary gland dysfunction (SGD)
- Define Xerostomia
- Define salivary gland hypofunction
- SGD: Any change in the QUALiTY or QUANTITY output of saliva caused by hyperfunction or hypofunction in salivary output
- Xerostomia: SUBJECTIVE sensation of dry mouth
- 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
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)
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
List six complications of xerostomia (“SGD” per 6th edition)
See pg 660
- General problems - oral discomfort, lip discomfort
- Eating related problems - anorexia, taste disturbance, difficulty chewing/swallowing, decreased intake
- Speech related problems
- oral hygiene - poor, halitosis
- Oral infections - candidiasis, dental carries, peridontal disease, salivary gland infections
- systemic infections - secondary to oral infection
- dental/dental prosthesis problems - dental erosion
- psychosocial problems - embarassment, anxiety, depression, isolation
- 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
- 3 signs of salivary gland hypofunction on physical exam.
- What discrepancy is important to note in patients with xerostomia?
- Signs:
- lips - dry, cracking
- tongue - fissuring
- mucosa - dry, absent of saliva pool on the floor of mouth - Patients with xerostomia (and some with SGH) may have no obvious abnormalities on exam
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?
- 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
- 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)
- What is the difference between sialorrhea vs. drooling
- Does a patient with drooling necessarily have sialorrhea?
- Sialorrhea is an excessive secretion of saliva
Drooling is abnormal spillage of saliva from mouth - Drooling is usually not related to sialorrhea
Many patients have salivary gland hypofunction rather than sialorrhea
List two broad mechanisms that lead to drooling
- Difficulty retaining salvia in mouth (facial weakness)
- Difficulty removing saliva from mouth (dysphagia)
List four drooling treatments (2 meds, 2 interventions)
anticholingeric drugs (glyco, scopolamine)
botulinum toxin A
parasympathetic nerve ablation
salivary duct relocation
List four approaches to manage thick, tenacious saliva
Treat source: Treatment of SGD (xerostomia)* Treat symptom: Hydration * Humidification* Oral rinsing (soda water, sodium bicarb)* dietary manipulation (ie avoidance of caffeine)
List 3 types of taste disturbance
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
List six causes of dysgeusia
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
List three dietary interventions for patients with dysgeusia
- Eat food that tastes good*
- avoid food that tastes bad*
- Zinc supplementation
- enhancing food that tastes good (ie. add salt, sugar)*
- modify temperature, consistency, presentation of food
List four risk factors for candida colonization
Patients with SGD
Dentures (upper)
Use of topical antibiotics
Use of topical steroids
List 4 manifestations of oral candidosis - which is the most common?
- Pseudomembranous candidosis (most common type)
- Erythematous candidosis
- Denture stomatitis
- Angular cheilitis
PEDA
List 2 complications of oral candidosis
- Esophageal candidosis (odynophagia + dysphagia) - frequent
- Candidemia - less frequent
How is a diagnosis of oral candidosis made?
List 2 reasons this is challenging
- Combo of clinical features + microbi investigations. (Diagnosis should be made if heavy growth on swabs)
- i) non-specific clinical features
ii) patients may be yeast carriers
List 3 important considerations in limiting drug resistance when prescribing anti-fungals for oral candidosis
- Only prescribe for microbiologically proven cases of oral candidosis
- Prescribe for shorter durations (longer promotes resistance)
- Prescribe in high doses (lower doses promote resistance)
What are 2 reasons for recurrent episodes of oral candidosis despite treating infection
- Underlying cause was not treated (i.e. treating SGD reduces recurrence)
- Lack of denture hygiene/disinfection
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.
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
List 3 topical antifungal agents for managing oral candidosis
Table 10.4.3:
- Polyene group - nystatin, amphotericin B
- Azole - miconazole, clotrimazole
- Other: chlorhexidine, gentian violet, tea tree oil
FS: CAN - clorhexidine, azole, nystatin
- List 3 reasons you should consider systemic rather than topical antifungal agents for oral candidosis?
- List 2 systemic antifungals
- Generalized infection
Persistent/recurrent infection
Infections in immune-suppressed patient
Fluconazole - 1st line
Itraconazole - for fluconazole resistant/refractory disease
Variconazole - refractory disease
FS: FIV
- Which virus causes primary herpetic gingivostomatitis (the most common viral infection of the mouth)?
- How do herpes viruses establish latent infections?
- What is the presentation of reactivation in immunocompetent vs immunosuppressed patients?
- Mostly HSV type 1
- HSV lies dormant in trigeminal ganglion
- IC = herpes labialis (cold sore)
IS = oral lesions, painful, crops of ulcers or florid, need lab testing to confirm diagnosis)
What is the HSV treatment approach for:
- Immunocompetent patients
- Immunosuppressed patients
Name 2 antiviral meds
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
- Define oral mucositis vs oral stomatitis
- Where does pain originate in oral mucositis?
- Oral mucositis is mucosal inflammation secondary to cancer treatment
VERSUS
Oral stomatitis is mucosal inflammation from other causes (infection/trauma) - Inflammation of the oral SUBmucosa (as opposed to ulceration of the mucosa)
- Which parts of the mouth are affected the most by oral mucositis?
- What are the 3 stages of oral mucositis?
- What is the most consistent symptom of oral mucositis?
- List 4 complications of oral mucositis
- What is the natural history of oral mucositis after chemo, rads, vs other source
- Non-keratinized surfaces affected most severely (mucosa of lips, cheeks, floor of mouth)
- Mucosa appears red —> white (desquamation) —> ulcerates (and exudative pseudomembrane forms)
- Pain - constant, aggravated by eating, drinking, oral hygiene. Severity of pain correlated with severity of mucositis. Some patients need opioids
- Dehydration
malnutrition
infection (local or systemic)
local hemorrhage
interference with cancer treatment - Self-limiting condition with recovery:
- 2 weeks after chemotherapy
- 3-4 weeks after XRT
- variable - some patients can have more chronic sx
List 3 non-medical and 3 medical treatment options for oral mucositis
What is the evidence for topical anesthetic and sulcrate?
- 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
- little/no evidence for topical anaesthetics or coating agents and sulcralfate mouthwash should not be used
What are 3 important points of education for family/HCPs providing oral care in the terminal phase?
- FREQUENCY of oral care should be individualized to patient need, not protocol based
- FAMILIES should be given the option to provide (with support) or opt out of oral care for their loved one
- Dry oral mucosa unlikely to be source of distress in unconscious PATIENT. But water-based moisturizing gel may be more effective than water
