Mouth Care Flashcards
1
Q
Maintenance of oral hygiene: Basics
A
Toothpaste/toothbrush (brush BID)
- Extra soft nylon toothbrush (bristles softened further with hot water), rinse between use and replace q3 months (or sooner if oral infection occurs)
- Electric toothbrush qith rotation-oscillation action may be better at removing plaque
- Mild, fluoridated, low-abrasive toothpaste. Consider unflavoured (can irritate mucosa)
- Consider secretagogue toothpastes for xerostomia
- Consider non-foaming toothpaste for patients with dysphagia
- If toothpaste is too irritating, soak in a saline solution or use plain water and also rinse the mouth with plain water or saline
- Toothetts, foam swabs not as effective
- Glycerine and lemon swabs inadequate for cleaning the oral cavity and glycerine can increase oral drying
Floss
- Once daily, unless hemostasis is an issue
2
Q
Oral Hygiene: Mouth Rinses
A
- May be useful for patients with xerostomia, but avoid alcohol which is drying
- Alternative: Saline/baking soda solution
Chlorhexidine gluconate oral rinse 0.12% BID
- Anti-plaque agent with effective antimicrobial and slight antifungal activity
- Will not remove established plaque
- Oral applicator (4 x 4 gauze on a stick) can be soaked and used to remove dried mucous and oral debris
- Use between brushing (some toothpaste additives can neutralize it) and ensure patients don’t rinse immediately after
- Causes tooth staining (corrected by dental cleaning)
- Can cause alterations in taste with prolonged use
- Not shown to be beneficial as prophylaxis or treatment of mucositis in rads or chemo - may be irritating
Hydrogen Peroxide rinse 1.5%
- Used to loosen and remove hardened debris and clean a coated tongue
- Can be irritating and may destroy health granulation tissue
- May increase and prolong severity of mucositis
- Indications: Fusobacterium oral infection
3
Q
Mouth Rinse: Hydrogen Peroxide
A
Hydrogen Peroxide rinse 1.5%
- Used to loosen and remove hardened debris and clean a coated tongue
- Can be irritating and may destroy health granulation tissue
- May increase and prolong severity of mucositis
- Indications: Fusobacterium oral infection
4
Q
Rinse for Fusobacterium oral infection
A
Hydrogen Peroxide rinse 1.5%
- Used to loosen and remove hardened debris and clean a coated tongue
- Can be irritating and may destroy health granulation tissue
- May increase and prolong severity of mucositis
- Indications: Fusobacterium oral infection
5
Q
Mouth rinse: Chlorhexidine
A
Chlorhexidine gluconate oral rinse 0.12% BID
- Anti-plaque agent with effective antimicrobial and slight antifungal activity
- Will not remove established plaque
- Oral applicator (4 x 4 gauze on a stick) can be soaked and used to remove dried mucous and oral debris
- Use between brushing (some toothpaste additives can neutralize it) and ensure patients don’t rinse immediately after
- Causes tooth staining (corrected by dental cleaning)
- Can cause alterations in taste with prolonged use
- Not shown to be beneficial as prophylaxis or treatment of mucositis in rads or chemo - may be irritating
6
Q
Denture care
A
- Should never be worn 24 hrs a day
- Daily brushing and soaking to avoid colonization, especially with candida
Cleaning:
- Denture brush and toothpaste specially formulated for dentures (regular toothpaste can damage)
- Stored in a well-identified container with either a denture cleaning solution or warm water
- Rinse mouth and dentures with water before reinsertion
Fit
- With emaciation, patients may complain that dentures are loose due to loss of oral fat pads
- Xerostomia may impact loss of denture adhesion
- Solution: Permanent denture reline or a temporary procedure with a commercial available kit to tighten the denture for a short period of time (2-6 weeks)
- Watch for tartar formation on dentures, which may cause irritation - requires professional cleaning
7
Q
Management of dentures in case of a suspected fungal infection
A
- Disinfect overnight in a dilute bleach solution (1 part 1% bleach: 80 Parts water) unless there is a metal clasp (can damage the metal component)
- Note household bleach is too strong, get specialised denture bleach
- May also use a topical antifungal (e.g. nystatin) to apply to the inner surface of the denture or brush the inside of the appliance
8
Q
Most likely causes of xerostomia
A
- Head and neck rads
- Mouth breathing
- Dehydration
- O2 therapy
Meds:
- TCAs (note desimpramine is less anticholinergic than amitriptyline)
- Antipsychotics
- Antihistamines
- Anticholinergics
- Opioids
- Anticonvulsants
- BB
- Diuretics
9
Q
How to manage xerostomia
A
- Oral hygiene
- Maintain moisture
- Ice chips
- popsicles
- Sugar free frozen fruit juice
- Tonic water
- Small sips of fluids or a water spray, and keep at bedside
- Use a humidifier in a room, especially during sleep - Stimulate saliva production (generally preferred)
- Sugarless gum or sugar free candy
- Ascorbic acid (relatively ineffective) or malic acid (more effective), but may cause oral discomfort, especially with mucositis or stomatitis - Artificial saliva or salivary substitutes
- Moisturizing gels may be very useful, keep at bedside and use sparingly on lips, tongue, and palate (taste may be an issue) - Specially formulated toothpaste
- Water based products for lip production
- Olive oil or sesame oil applied sparingly to mucosa
- May combat dryness and facilitate denture adhesion and comfort - Dietary tips
- Soften food or use purees
- Avoid dry foods (biscuits, cereal)
- Avoid caffeine containing drinks or alcohol - Drugs for salivary stimulatio
- Pilocarpine (often used with Sjogren’s etc.) - parasympathomimetic, side effects include sweating, HA, urinary frequency, vasodilatation
10
Q
Stomatitis
A
- Mucosal irritation
Due to:
- Intraoral fungal or herpetic infection in immunosuppressed patients
- Necrotizing gingivitis (fusobacterial origin) in patients with extremely poor oral hygiene
- Erosive lichen planus
11
Q
Mucositis
A
- Mucosal irritation, but typically used in reference to erythematous and ulcerative lesions caused by cancer therapies (rads, chemo, SCT)
- Can involve oral mucosa and other areas of the GI tract
Consequences:
- Pain/distress
- Nutritional compromise
- Increased susceptibility to local/systemic infections
12
Q
Candidiasis
A
- Fungal infections common in medically complex patients
- C. Albicans (most common), but other Candida species or aspergillus may be found
Risk factors:
- Immunosuppression
- HIV/AIDs
- Cancer tx
- Xerostomia
- DM (uncontrolled)
- Poor oral hygiened
- Prolonged used of dental prothesis
- Poor nutritional status
- Iron deficiency
- Oral steroids or steroid inhalers
- Antibiotic use
13
Q
Presentation of candidiasis
A
- Presentation may be multiple forms simultaneously
- Initial presentation often angular cheilitis
- S. aureus may be a secondary contributing pathogen
- Pseudomembranous form (thrush)
- White, yellowish plaques that can be wiped off, with erythematous mucosa beneath
- Most commonly on palate, buccal mucosa, dorsal tongue - Acute erythematous form (acute atrophic candidiasis)
- Erythematous, painful, atrophic areas on the palate or dorsal surface of the tongue
- Burning sensation, bitter or metallic taste - Chronic erythematous form (chronic atrophic candidiasis)
- Chronic erythema, edema, and small erosions or plaques with with a velvet texture
- Often found on the hard palate where the upper denture fits - Chronic hyperplastic candidiasis
- Leukoplakia-esque, with white or discoloured plaques that cannot be wiped off
- Associated with a burning sensation
- Often on the buccal mucosa or laterodorsal tongue
14
Q
Candidiasis: Pseudomembranous form
A
Pseudomembranous form (thrush)
- White, yellowish plaques that can be wiped off, with erythematous mucosa beneath
- Most commonly on palate, buccal mucosa, dorsal tongue
- Most common form of candidiosis
15
Q
Candidiasis: Acute erythematous form
A
Acute erythematous form (acute atrophic candidiasis)
- Erythematous, painful, atrophic areas on the palate or dorsal surface of the tongue
- Burning sensation, bitter or metallic taste
16
Q
Candidiasis: Chronic erythematous form
A
Chronic erythematous form (chronic atrophic candidiasis)
- Chronic erythema, edema, and small erosions or plaques with with a velvet texture
- Often found on the hard palate where the upper denture fits
17
Q
Candidiasis: Chronic hyperplastic form
A
Chronic hyperplastic candidiasis
- Leukoplakia-esque, with white or discoloured plaques that cannot be wiped off
- Associated with a burning sensation
- Often on the buccal mucosa or laterodorsal tongue
18
Q
Diagnosis of Candidiasis
A
- Typically by visual inspection
- Can use stained smears in the lab to demonstrate characteristic hyphae - requires heavy growth (light growth suggests colonization)
- Colonization may not confirm infection (C. albicans is part of normal flora)
19
Q
Treatment of candidiasis
A
*Maintain oral hygiene and ensure dentures are disinfected
Pseudomembranous/thrush and erythematous forms:
- Topical or Systemic
Hyperplastic candidiasis:
- Systemic Rx
Topical:
- Nystatin 100 000 U/mL swish and swallow 5mL QID x 7-14 days. Patient must not rinse mouth for 20 mins after use
- Antifungal troche - Clotrimazole 10mg ODT 3-5x/day
- Both must be continued a few days after lesions disappear
- Both contain sugar and may impact diabetic chemstrips and increase risk of dental caries
Systemic:
- Fluconazole 100-200mg PO daily x 7-14 days
- If refractory to fluconazole, go to itraconazole or posaconazole
- Note azoles are potent CYP450 and can interact with methadone, haldol, and warfarin
Angular cheilitis
- Topical antifungal ointment
20
Q
Topical treatments for oral candidiasis
A
Indications:
- Pseudomembranous/thrush
- Erythematous forms (acute or chronic)
- Nystatin 100 000 U/mL swish and swallow 5mL QID x 7-14 days. Patient must not rinse mouth for 20 mins after use
- Antifungal troche - Clotrimazole 10mg ODT 3-5x/day
- Both must be continued a few days after lesions disappear
- Both contain sugar and may impact diabetic chemstrips and increase risk of dental caries
21
Q
Systemic treatments for oral candidiasis:
A
Indications:
- Pseudomembranous/thrush - moderate/severe
- Erythematous forms (acute or chronic) - moderate/severe
- Hyperplastic candidiasis
- Immunocompromised (more likely to be effective)
Systemic:
- Fluconazole 100-200mg PO daily x 7-14 days
- If refractory to fluconazole, go to itraconazole or posaconazole
- Note azoles are potent CYP450 and can interact with methadone, haldol, and warfarin
22
Q
Pain management for mucositis: Approach
A
- Identify all possible causes of pain
- Reduction of contributing factors
- Optimize basic oral hygiene and treat any infections
- Give analgesics either topically, systemically, or both
- Consider advice from a dietician to optimize fluid and nutritional intake
23
Q
Pain management for mucositis: Topical anesthetics and mucosal coating agents
A
Topical anesthetics
- Lidocaine 2% viscous oral solution 5ml - 15ml q3-4 hrs
- Lidocaine 10% spray
- Lidocaine gel
- Can cause irritation and suppress gag reflex, ensure patients do not eat or drink while mouth is numb
- Rinse with water first, then use lidocaine and spit once mouth is coated
Coating agents
- Antacids (magnesium hydroxide or alumnium hydroxide)
- Sucralfate (not recommended for rads-induced mucositis)
- Bismuth Salicylate (Kaopectate)
Miscellaneous
- Morphine oral rinse (15mls 2% morphine up to 6x/day, gargle and spit)
- Diphenhydramine (anti-inflammatory)
- Magic mouthwash (30 mls nystatin, 120mls diphenhydramine, 50mg hydrocort, with sterile water) - swish and spit
24
Q
Signs of a oral bacterial infection in cancer patients
A
- May be superimposed on acute oral mucositis
- Increase risk of systemic infection
- Symptoms may be masked in patients who are severely immunosuppressed
- Typically mixed pathogens
Signs:
- Pain
- Lesions
- Fever
25
Q
HSV-1 in cancer patients
A
- Herpes simplex commonly seen in immunosuppressed patients
- Typically due to reactivation of latent virus
- May present as typical herpes lesions to extensive mucositis, with or without extra-oral lesions
- Intra oral lesions usually found on ‘fixed’ mucosa (hard palate, gingiva)
- May coalesce, form large ulcerations, or appear hemorrhagic
Diagnosis:
- May require viral culture
Treatment
- Systemic antivirals if severe and in immunocompromised patients
26
Q
Causes of poor fitting dentures
A
Fit
- With emaciation, patients may complain that dentures are loose due to loss of oral fat pads
- Xerostomia may impact loss of denture adhesion
- Solution: Permanent denture reline or a temporary procedure with a commercial available kit to tighten the denture for a short period of time (2-6 weeks)
- Watch for tartar formation on dentures, which may cause irritation - requires professional cleaning
27
Q
Consequences of xerostomia
A
- Discomfort (oral, lip)
- Eating-related problems (difficulty chewing/swallowing, taste disturbance, decreased PO intake)
- Speech-related problems
- Oral hygiene (halitosis, bacterial proliferation)
- Systemic infections (secondary to oral infection)
- Dental/denture problems
- Other - sleep disturbance, difficulties with SL/buccal meds, esophagitis, urinary frequency secondary to increased PO intake
28
Q
Sialorrhea
A
- Typically due to facial weakness/deformity and difficulty retaining saliva rather than true sialorrhea
Treatment: - Anticholinergics (e.g. oral glycopyrronium, atropine drops PO)
- Botox
- Parasympathetic nerve ablation
29
Q
Taste disturbance in cancer
A
- Reduction in taste (hypogeusia), absence of taste sensation (ageusia), or distortion of taste (dysgeusia)
- Common in advanced cancer and especially with head and neck CA
- May have significant impact on QOL
Causes
- Damage to taste buds, cranial nerves, CNS
- Cancer treatment (surgery, local rads, chemo)
- Oral issues (salivary gland dysfunction, poor oral hygiene, oral infections)
- Metabolic problems (renal dysfunction)
30
Q
Treatment of taste disturbance
A
- Manage xerostomia
- Zinc therapy has weak evidence - trial PO supplement
Dietary intervention (mainstay)
- Avoidance of foods that taste bad
- Use of flavour enhancers (sugar, salt, etc.)
- Addressing presentation, smell, and consistency of foods
- Involve a dietician
