Oral Care - CBM and Oxford Flashcards
1
Q
How common and important are oral problems in cancer patients?
A
- Very common
- head and neck RT
- Myelosuppressive chemotherapy
- advanced cancers
- Pain, poor nutritional intake, risk of infection, interruption of treatment
- H and N RT patients can have chronic oral health problems:
- xerostomia, tooth decay, impaired taste
- Full dental exam prior to treatment
2
Q
Oral hygiene
A
- Mechanical plaque control
- extra soft nylon brush
- soften bristles under hot water
- mild fluoridated low abrasive toothpaste (1000 ppm)
- Non foaming toothpaste
- saline solution
- rinse tooth brush, replace q 3 months
- Foam swabs not as good to clean
- floss if possible
- Mouth rinses
- decreased saliva, halitosis
- most contain alcohol –> increased xerostomia
- baking soda / saline solution (1 tsp salt in 4 cups H20, 1 tsp baking soda in 1 cup H20)
- alcohol free formulation
- Chlorhexidine gluconate oral rinse
- 0.12% diluation. 15 ml for 30 second and spit
- use between brushings
- staining of teeth, alters sense of taste
- not useful in mucositis
- Hydrogren peroxide oral rinse 1.5%
- loosen debris, cleans coated tongue
- irritating to oral mucose, destroys granulation tissue, may prolong mucositis
- use mainly for fusobacterium oral infections
- Denture care:
- leave out overnight
- candida infections
- daily brushing and soaking, special toothpaste
- disinfect by soaking overnight in bleach solution (1part bleach: 80 parts water)
- loose dentures : fat loss, xerostomia. Reline kit,
3
Q
Xerostomia - etiology
A
- XEROSTOMIA :subjective feeling dry mouth
- SALIVARY GLAND HYPOFUNCTION: objective reduction in saliva
- Xerostomia can also be caused by change in composition of saliva
- Causes:
- medications
- Head and neck RT
- progressive debilitation causing mouth breathing
- dehydration
- 02 therapy
- malnutrition
- tumour infiltration, paraneoplastic syndrome
- Culprit medications
- TCA
- Neuroleptics (phenothiazines)
- Antihistamines
- anticholinergics
- Opioids
4
Q
Xerostomia - managment
A
- Review medications
- meticulous oral hygiene
- keep mouth moist (suck on ice chips, popsicles, tonic water)
- Small sips of water
- saliva stimulants : gum, lemon candy, organic acids
- Artifical saliva and salivary substitutes
- neutral pH, easy to use.
- Specially formulated toothpaste
- lip protection with water based products
- olive oil/sesame oil to mucosa.
- Maintain humidity in room
- secretagogues/ parasympathomimetic drugs
- Stimulate ANS
- pilocarpine, pyridostigmine
- SE: sweating, headache, Urinary frequency, vasodilation
- change diet (soft foods, purees, avoid dry foods, avoid caffeine and alcohol)
- acupuncture
5
Q
Stomatitis - Mucositis
A
- Mucosal irritation
- Stomatitis (general). Causes:
- erosive lichen planus
- necrotizing gingivitis of fusobacterial origin
- infection (fungal or herpetic)
- Mucositis (caused by treatment)
- HN radiation
- chemotherapy
- stem cell transplant
- can involve oral mucosa and other parts of GI tract
- severe pain, distress, compromised nutrition, increased infection
6
Q
Oral candidiasis - Causes
A
- Candida albicans, aspergillus, other candida spp.
- Risk factors:
- HIV/AIDS
- immunosuppressive drugs
- RT / chemo
- xerostomia
- uncontrolled diabetes
- poor oral hygiene
- prolonged use of oral appliances
- poor nutrition
- Fe deficiency
- oral or inhaled corticosteroids
- use of antibiotics (controversial)
- Steroids (topical > systemic)
7
Q
Oral Candidiasis : Clinical Manifestations
A
- Bilateral angular cheilitis (cracking at corners of mouth)
- Pseudomembranous form (THRUSH)
- white, yellow plaques
- scraped off
- underlying erythematous mucosa
- palate, buccal mucosa, dorsal tongue
- Acute erythematous form (acute atrophic candidiasis)
- erythematous, painful and atrophic areas on palate or tongue
- Chronic atrophic candidiasis / denture stomatitis
- hard palate
- Same as acute, but more edema, velvet texture
- Chronic hyperplastic candiasis
- similar to leukoplakia
- white plaques that cannot be wiped off.
- Painful burning
- buccal mucosa near commissures or lateral sides of tongue
- Esophageal candidiasis
- odynophagia, dysphagia
- confirmed on esophagoscapy
- Barium swallow : fluffy punched out lesions along esophagus
8
Q
Oral candidiasis : treatment
A
- Pseudomembranous and erythematous forms - oral or systemic treatment
- Hyperplastic candidiasis - systemic only
- angular cheilitis - topical antifungal
TOPICAL ANTIFUNGALS
- Nystatin 100 000 u/ML 5 ml QID x 7-14 days. Swish and swallow
- contain sugar, watch in diabetics
- increases caries with prolonged use
- Amphotericin B 1ml suspension qid x 14 days
- Clotrimazole 10 mg 5x/day x7-14 days
- Chlorhexidine, gentian violet, tea tree oil
SYSTEMIC ANTIFUNGALS
- Fluconazole 100-200 mg po od x 7-14 days
- Itraconazole oral solution/cap
-
AZOLES potent inhibitors of cytochrome p450
- drug-drug interactions with methadone, haldol, warfarin
- Maintain excellent oral hygiene
9
Q
Management of oral pain
A
- identify causes
- reduction of factors
- optimization of hygiene
- treatment of infection
- topical analgesics or systemic analgesics
- Dietitian support for optimization of nutrition
10
Q
Topical Anesthetics and mucosal coating agents
A
- Bland rinses (saline, baking soda)
- Morphine oral rinse (15 ML 2% morphine solution) 6x/day , swish and spit
- PCA for severe stomatitis
- see attached chart
11
Q
Other common oral infections
A
- Bacterial infections :
- odontogenic, gingival, mucosal
- Viral infections
- HSV 1 (herpes simplex)
- herpes labialis, extensive mucositis
- small tense vesicles, ulcerations, hemorrhagic, pseudomembranes on hard palate, gingiva
- secondary infections
- antivirals
- CMV, VZV, EBV, etc
12
Q
List oral symptoms
A
- dry mouth
- mouth pain
- dysgeusia
- difficulty speaking
- dysphagia
- odynophagia
- difficulty chewing
- mouth sores/mucositis
- oral infections (candida, gingivitis, caries, salivary gland infection)
- Systemic infections
- dental/prosthesis problems
- psychosocial problems (emabarrassment, anxiety, social isolation)
- sleep/increased fluids/esophagitis
13
Q
Taste disturbance
A
Hypoguesia (reduced taste)
Ageusia (no taste)
Dysguesia (abnormal taste)
Etiology:
- damage to taste bud
- CN damage
- surgery
- Radiation
- chemotherapy
- xerostomia
- infection
- zinc dysfunction
Treatment
- choose appealing foods
- enhance taste (salt, sugar, spices)
- Address presentation, smell, consistency, temperature
- oral zinc supplements
14
Q
Xerostomia vs salivary gland dysfunction - physical exam
A
- dry oral mucosa
- dry cracked lips
- absence of pool of saliva on floor of mouth
- fissuring of oral mucosa and tongue
- Xerostomia is subjective so may not see findings
15
Q
Sialorrhea and Drooling and Tenacious saliva
A
- Sialorrhea : Excessive secretion of saliva
- Drooling: abnormal spillage of saliva from mouth.
- facial weakness
- dysphagia
- may have salivary gland HYPOFUNCTION actually
- ACH : glycopyrronium bromide, hyoscine hydrobromide, botox
- Parasympathetic nerve ablation
- Tenacious saliva
- treat dehydration, oral rinsing, humidification, BB, fruit juices