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
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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,
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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
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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
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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
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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)
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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
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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
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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
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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
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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
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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
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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
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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
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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
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