Oral Cavity Disorders

Overview of the Oral Cavity

• The digestion of food begins in the oral cavity.
• The pharynx (throat) is the passage between the mouth and the gastrointestinal (GI) tract.
• The pharynx plays a critical role in both digestion and gas exchange.
• Oral cavity disorders can affect:
    - Nutrition
    - Speech
    - Body image
    - Self-esteem

Risk Factors for Oral Cavity Disorders

• Developmental delays or mental health disorders
• Homelessness or decreased access to care, especially for those in institutions
• Use of tobacco or alcohol
• Consumption of an unhealthy diet
• Oral cancer

Care of the Oral Cavity

• Maintain a well-balanced diet.
• Brush and floss teeth twice daily.
• Conduct a self-exam of the mouth weekly.
• Avoid drugs that can cause:
    - Inflammation of the mouth
    - Reduced saliva production
    - Irritation due to alcohol-based mouthwash
• Schedule regular visits with the dentist.
• Ensure that dentures fit properly and are in good repair.

Stomatitis

• Definition: A broad term referring to inflammation within the oral cavity.
• Classification of Stomatitis:
    - Primary Stomatitis: Most common type. Subtypes include:
      - Aphthous stomatitis
      - Herpes simplex stomatitis
      - Traumatic ulcers
      - Common dietary triggers for aphthous ulcers include:
        - Coffee
        - Potatoes
        - Cheese
        - Nuts
        - Citrus fruits
        - Gluten
    - Secondary Stomatitis: Infections caused by opportunistic organisms in immunocompromised patients.
      - Long-term antibiotic therapy can lead to overgrowth of Candida albicans, causing Candidiasis (Thrush).
      - Symptoms: white plaque-like lesions that are painful; if wiped away, the surface is red and sore.

Assessment of Stomatitis

• Collect a history of:
    - Recent infections
    - Nutritional changes
    - Oral hygiene habits
    - Oral trauma
    - Stress levels
• Drug history should include over-the-counter medications and nutritional or herbal supplements.
• Evaluate current symptoms:
    - Do lesions interfere with swallowing, eating, or communication?
• Conduct oral assessments using gloves and a pin light for adequate lighting.
• Assess for:
    - Lesions
    - Cracking of the mouth
• Document characteristics of lesions, including:
    - Location
    - Size
    - Shape
    - Odor
    - Color
    - Drainage
• For advanced practice providers: palpate cervical and submandibular lymph nodes for swelling.
• Be alert for symptoms of Dysphagia (difficulty swallowing).

Interventions for Stomatitis

• Oral Hygiene:
    - Use a soft-bristle toothbrush or a disposable foam swab for cleansing the oral cavity.
    - Employ alcohol-free toothpaste and mouthwash.
    - Rinse mouth every 2-3 hours using sodium bicarbonate or warm saline to alleviate pain.
    - Gentle debridement of lesions may help prevent super infections.
• Drug Therapy:
    - Use antimicrobials (antibiotics, antivirals, antifungals).
    - Tetracycline syrup can be rinsed and swallowed; Minocycline can be used as a swish-and-swallow.
    - Chlorhexidine mouthwashes may be prescribed for certain patients.
    - For immunocompromised patients with herpes simplex stomatitis: IV Acyclovir may be provided.
    - Nystatin prescribed for a yeast infection; lozenges of antifungal preparations can dissolve slowly for analgesic effects.
    - Immune modulators (topical) may also be used.
    - Symptomatic topical agents such as over-the-counter Benzocaine and Camphor-Phenol, or Viscous Lidocaine (caution due to burn risk with hot liquids).
    - Magic Mouthwash may include Lidocaine, Benadryl, Maalox, Carafate, and glucocorticoids.
• Dietary Changes:
    - Encourage cool or cold liquids.
    - Avoid spicy, salty, or acidic foods.
    - High-protein and high-vitamin C foods (scrambled eggs, bananas, custards, pudding, ice cream) can promote healing.

Oral Tumors

Premalignant Lesions

• Two types:
    - Leukoplakia:
      - Characterized by thickened, white, firmly attached patches on oral mucosa.
      - Commonly benign; lesions on lips or tongue may progress to cancer.
      - Oral hairy leukoplakia presents in HIV patients due to chronic irritation (e.g., from poorly fitting dentures).
    - Urethroplakia:
      - Appears as red, velvety mucosal lesions and is considered pre-cancerous.
      - Requires biopsy; commonly found on floor of the mouth, tongue, palate, and mandibular mucosa.

Oral Cancer

• Patients should have regular dental evaluations (minimum of twice yearly) for hygiene and cancer screenings.
• Prevention measures include:
    - Minimizing exposure to the sun and tanning beds
    - Tobacco cessation
    - Reducing alcohol intake
• Squamous Cell Carcinoma:
    - Slow-growing; early signs include mucosal erythroplasia (red, raised lesions).
    - Symptoms: a lesion that does not heal within two weeks, lumps, or thickening of the cheek warrant further assessment.
    - Risk factors: increasing age, tobacco and alcohol use; higher risk in certain occupations (textile, plumbing, coal, and metalwork).
    - Poor nutrition, hygiene, and HPV infection increase risks.
• Basal Cell Carcinoma:
    - Malignant lesions, commonly presenting as raised, scab-like on lips; evolves to an ulcer with a pearly border, typically does not metastasize but can cause significant local tissue involvement.
    - Major risk factor is excessive sunlight.
• Kaposi’s Sarcoma:
    - Appear as raised purple nodules/plaque; painless lesions typically found on hard palate but can occur in gums, associated with AIDS.

Assessment of Oral Cancer

• Evaluate oral hygiene regimen, denture use, history of oral bleeding, and nutritional state (ask about difficulties in chewing, swallowing).
• Perform thorough oral assessments:
    - Look for lesions, changes in speech due to tongue movement, voice alterations, and assess saliva for thickness or absence.
• Diagnostic tests include:
    - Oral CDX: A brush test performed by dentists to screen for pre-cancerous conditions.
    - Biopsy: Definitive diagnostic test for oral cancer.
    - Imaging tests (CT, MRI) to assess for metastasis.

Interventions for Oral Cancer

Medical Interventions

• Non-surgical Management:
    - Manage the patient’s Airway: Promote air exchange, secretions removal, and aspiration prevention.
    - Assess for dyspnea due to obstruction or excessive secretions.
    - Promote adequate gas exchange (Fowler's position, increased fluid intake).
    - Use steroids to reduce edema; antibiotics for infections; consider cool mist face tent.
    - Oral Hygiene: Implement a routine every two hours with a soft-bristled toothbrush.
    - Avoid commercial mouthwashes or lemon glycerin swabs due to irritation; rinse frequently with sodium bicarbonate or warm saline.
• Radiation Therapy:
    - Used to shrink tumors before surgery.
    - External Beam: Radiation that passes externally to reach the tumor site.
    - Interstitial Implantation: Delivers high-dose radiation closer to the tumor bed and requires precautions (private room, limited visitor exposure).
• Surgical Management:
    - Options include cryotherapy, local anesthesia excisions, or extensive surgeries.
    - Types of extensive surgical excisions:
      - Partial/Total Glossectomy: Removal of the tongue.
      - Partial Mandibulectomy: Removal of part of the jaw.
      - Commando Procedure: Combined removal of mandible and adjacent tissues.
      - Radical Neck Dissection: Removal of affected cervical lymph nodes, cranial nerves, internal jugular vein, and sternocleidomastoid muscle.
    - Pre-operative assessments may include dietary restrictions, activity limitations, and IV lines for medications.

Post-operative Care

• Patients may require temporary or permanent tracheostomy and pain relief; nutrition via NG tube or TPN.
• Oral care every four hours; elevate the head of the bed to minimize edema.
• Encourage speech therapy to promote swallowing exercises.
• Anticipate complications from radiation: mucositis, stomatitis, taste alterations, and dental decay.
• Follow-up dental care is essential.
• Use saliva substitutes as needed to manage dry mouth.

Acute Sialadenitis

• Definition: Inflammation of salivary glands due to infections, immune disorders, or radiation.
• Causes:
    - Viral/Bacterial agents such as cytomegalovirus, Staphylococcus aureus, Streptococcus pneumoniae, and E. coli.
    - Medications (e.g., tetracyclines, phenothiazines) can lead to reduced saliva flow.
    - Untreated infections may progress to abscesses.
    - Sjogren's Syndrome: Chronic inflammatory condition causing dry mouth.

Assessment for Acute Sialadenitis

• Assess risk factors, drug history, systemic illnesses, and hydration status (look for dehydration signs).
• Check for swelling, facial pain, cranial nerve function, fever, malaise, and drainage.

Interventions for Acute Sialadenitis

• Provide IV fluids for hydration.
• Apply warm compresses and massage the affected glands.
• Use saliva substitutes and cyagogues (e.g., lemon slices, citrus candies) to stimulate saliva flow.
• Elevate the head of the bed for comfort if swelling occurs.

Salivary Gland Tumors

• Rare, slow-growing, often painless.
• Submandibular and minor salivary gland tumors may be painful.
• Tumors may invade nearby nerves, resulting in facial weakness or impaired tongue movement.

Assessment for Salivary Gland Tumors

• Check cranial nerve functions (e.g., abilities to wrinkle brow, raise eyebrows, smile).
• Be alert to any asymmetries.

Treatment for Salivary Gland Tumors

• Includes surgical excision, radiation for large or recurrent tumors, especially if there's residual disease or malignancy.
• Parotidectomy: Removal of parotid glands, with risk for facial nerve function loss.

Conclusion

• Nursing interventions for patients undergoing salivary gland tumor excision are similar to oral cancer surgeries.

• Maintain open lines of communication for questions and concerns.

• For any further inquiries or clarifications, please reach out via email or bring questions to the Q&A session.