Care of Patients with Oral Cavity and Esophageal Problems

Concepts

Priority Concept

  • Tissue integrity

  • Nutrition

Interrelated Concepts

  • Gas Exchange

  • Pain

A Healthy Oral Cavity

  • Eat a well-balanced diet and stay hydrated.

  • Manage stress.

  • Perform weekly self-examination of mouth.

  • Report changing conditions.

  • Ensure dentures are in good repair and fit.

  • Brush and floss teeth twice daily.

  • Avoid alcohol-based mouthwash.

  • Avoid drugs that increase inflammation.

  • See the dentist regularly.

Stomatitis

Pathophysiology Overview

  • Inflammation in the oral cavity.

  • Causes painful, inflamed ulcerations.

  • Classified according to the cause of inflammation.

Etiology and Genetic Risk

Primary Stomatitis

  • Most common type.

  • Includes:

    • Aphthous stomatitis (noninfectious stomatitis)

    • Herpes simplex stomatitis

    • Traumatic ulcers.

Secondary Stomatitis

  • Generally results from infections by opportunistic viruses, fungi, or bacteria in those who are immunocompromised or due to chemotherapy, radiation, or steroid drug therapy.

  • Example:

    • Candida albicans: Can overgrow due to long-term antibiotic therapy.

    • Resulting condition is candidiasis (moniliasis), which is a painful fungal infection.

Risk Factors

  • Older adults are at high risk for candidiasis due to a decline in immune system function with age.

  • Increased risk in diabetes, malnourished individuals, or those under significant stress.

  • Multiple medications can contribute to oral dryness and decreased salivation.

  • Teaching proper mouth care is essential for preserving tissue integrity as prevention is easier than treatment.

Incidence and Prevalence

  • Recurrent Aphthous Stomatitis (RAD) affects approximately 20% of the general population.

  • Incidence is higher in females.

Health Promotion and Management

Proper Oral Hygiene Practices:

  • Eat a balanced diet and drink water regularly.

  • Stress management through healthy coping mechanisms.

  • Weekly self-examinations; report unusual findings.

  • Report issues such as teeth occlusion or pain to health provider.

  • Ensure dentures fit properly.

  • Consistent brushing and flossing twice daily or brushing dentures.

  • Avoid alcoholic mouthwashes to protect tissue integrity.

  • Avoid any drugs that may inflame the mouth or reduce saliva flow.

  • Schedule regular dental visits.

Assessment: Recognizing Cues

History

  • Recent infections.

  • Changes in nutrition.

  • Oral hygiene habits.

  • Trauma history and stress factors.

Physical Assessment/Signs & Symptoms

  • Inspect for lesions, coating, and cracking.

  • Document characteristics of lesions based on location, size, shape, odor, color, and drainage.

  • Watch for dysphagia (difficulty swallowing) or throat pain indicating potential extensions into the esophagus.

  • Prescribing additional swallowing studies may be needed for a definitive diagnosis.

Analysis: Analyze Cues & Prioritize Hypotheses

  • Primary hypotheses include:

    • Impaired tissue integrity

    • Pain

Action Alert

  • Dysphagia can lead to airway obstruction, aspiration pneumonia, and malnutrition.

  • Signs to assess: coughing or choking while swallowing, sensation of food getting stuck in the pharynx.

  • Use the PASS acronym for assessment:

    • Probable swallowing difficulty?

    • Account for previous swallowing issues.

    • Screen for symptoms.

    • SLP referral.

  • Report findings to primary health care provider and implement aspiration prevention interventions.

Planning and Implementation: Solutions & Action

Preserving Tissue Integrity

  • Expected Outcomes: Patient will regain a healthy oral cavity with intact tissue integrity.

  • Interventions:

    • Health promotion and risk reduction through careful oral hygiene.

    • Delegate oral care to assistive personnel (AP) as this is within their skill set; inspect after completion.

    • Drug therapy includes pain management and infection control, with common drugs listed:

    • Clotrimazole troches

    • Nystatin suspension (swish and spit)

    • Chlorhexidine (swish and spit)

Minimizing Pain

  • Expected Outcomes: Patient will experience minimized pain or discomfort.

  • Interventions:

    • Suggest dietary changes: cool liquids for soothing effect; avoid hard, spicy, salty, and acidic foods.

    • Include high-protein foods to promote healing.

    • Recommend vitamin C supplements; however, be cautious with citrus intake due to potential pain.

    • Over-the-counter oral anesthetics can be suggested.

    • Prescription medications for pain include:

    • Viscous lidocaine

    • Diphenhydramine liquid

    • Aluminum hydroxide, magnesium hydroxide, and simethicone suspension

Drug Alerts

  • Exercise caution with viscous lidocaine due to its anesthetic properties; decreased sensation can lead to burns from hot liquids, increasing aspiration risk.

Patient Care Strategies

  • Remove dentures in cases of severe stomatitis or oral pain.

  • Encourage clients to maintain oral hygiene, brushing twice daily or more often as needed.

  • Provide mouth care every 2 hours or more if stomatitis persists.

  • Use soft toothbrush or gauze, and sodium lauryl sulfate (SLS)-free toothpaste; avoid irritants such as mouthwashes and lemon-glycerin swabs.

  • Rinse with warm saline or sodium bicarbonate solutions frequently.

  • Guide soft, bland food selections and apply prescribed topical analgesics or anesthetics.

Evaluation: Outcomes

  • Expectation of healthy oral mucosa without inflammation or infection.

  • Aim for minimized or absent pain.

Oral Tumors: Premalignant Lesions

Erythroplakia

  • Appears as red, velvety mucosal lesions on floor of mouth, tongue, palate, and mandibular mucosa.

  • Often difficult to distinguish from inflammatory or immune reactions.

Leukoplakia

  • Characterized by thickened, white, firmly attached patches on oral mucosa.

  • Commonly benign but lesions on lips or tongue can progress to cancer.

  • Tobacco use increases risk for leukoplakia development.

Hairy Leukoplakia

  • Visible sign of HIV infection with white plaques on the tongue.

Oral Cancer

Regular Dental Visits

  • Essential to visit dentist twice a year for oral cancer screenings.

  • Certain occupational exposures increase cancer risk:

    • Textile workers, plumbers, and metal workers exposed to polycyclic aromatic hydrocarbons (PAHs), especially with HPV exposure.

    • Existing periodontal disease as a risk factor.

Risk Assessment

  • Identify the individual at highest risk for oral cancer among the following:

    • 28-year-old with HPV infection

    • 30-year-old with recurrent aphthous stomatitis

    • 55-year-old who quit chewing tobacco 5 years ago

    • 76-year-old who is sometimes negligent in denture care

Types of Oral Cancer

  • Mostly squamous cell carcinomas present on lips, tongue, buccal mucosa, and oropharynx.

  • Basal cell carcinoma primarily found on lips related to sunlight exposure, resembling a raised scab evolving to an ulcer with a raised, pearly border.

  • Kaposi’s sarcoma seen as painless purple, reddish, or brownish nodules associated with AIDS (HIV-III).

Oral Cancer Assessment: Recognize Cues

  • Symptoms to assess:

    • Oral bleeding

    • Poor appetite or compromised nutritional status

    • Difficulty chewing or swallowing

    • Unplanned weight loss

    • Thick or absent saliva

    • Painless oral lesions that are red, raised, or eroded

    • Thickening or lump in the cheek

Oral Hygiene Regimen

  • Assess use of dentures or other oral appliances, oral bleeding, alcohol or tobacco usage, and eating difficulties.

    • Evaluate for cultural, spiritual, or educational needs affecting treatment or health teaching.

    • Review support systems in place for the patient.

Diagnostic Tests

  • EGD with biopsy for inspection and tissue specimen collection.

  • Positron emission tomography (PET) for metastatic disease identification and treatment evaluation.

Esophageal Tumors

Pathophysiology Overview

  • Tumors can be either benign or malignant, with more than half metastasizing.

  • Risk factors include:

    • Alcohol intake

    • Diet lacking fresh fruits and vegetables

    • Diet high in nitrates and nitrosamines

    • Malnutrition

    • Obesity, especially with abdominal pressure

    • Smoking

    • Untreated GERD

Assessment: Recognize Cues

  • Monitor for persistent and progressive dysphagia (most common feature), food sticking sensation, odynophagia, halitosis, chronic hiccups, cough, hoarseness, chest pain, and gastrointestinal changes such as regurgitation and unintentional weight loss.

Diagnostic Assessment

  • EGD with biopsy for cell studies.

Esophageal Trauma

Causes

  • Blunt injuries, chemical burns, surgery or endoscopy, and continuous severe vomiting.

Treatment

  • Maintain NPO for esophageal rest, prevent sepsis, and consider surgical options when necessary.

Case Studies

Case Study 1

  • 60-year-old client awaiting biopsy results with concerns about potential cancer:

    • Appropriate response is to validate concerns and inform about the provider's upcoming review of options.

Case Study 2

  • Client with a significant smoking and alcohol history asks about cancer risk:

    • Responses should focus on education about risk factors and prevention.

Case Study 3

  • Small localized esophageal malignancy receiving photodynamic therapy (PDT):

    • Teach about the procedure's purpose and expected outcomes.

Case Study 4

  • Monitoring for post-esophageal dilation and stenting complications:

    • Watch for immediate and long-term complications.

Questions

  • Questions cover various assessments and interventions related to oral and esophageal health, focusing on risk factors, assessment outcomes, priorities, and educational needs for patients with stomatitis, GERD, and esophageal issues.