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CHAPTER 53 Care of Patients with Oral Cavity Problems

Terms in this set (42)

When providing mouth care for the patient, you may delegate oral care to unlicensed assistive personnel (UAP). Remind UAP to use a soft-bristled toothbrush or disposable foam swabs to stimulate gums and clean the oral cavity and to use toothpaste that is free of sodium lauryl sulfate (SLS), if possible. Teach the patient to rinse the mouth every 2 to 3 hours with a sodium bicarbonate solution or warm saline solution (may be mixed with hydrogen peroxide). He or she should avoid most commercial mouthwashes because they have high alcohol content. Teach the patient to check the labels for alcohol content. Frequent, gentle mouth care promotes débridement of ulcerated lesions and can prevent superinfections. Drug therapy used for stomatitis includes antimicrobials, immune modulators, and symptomatic topical agents. Antimicrobials, including antibiotics, antivirals, and antifungals, may be necessary for control of infection. Tetracycline syrup may initially be prescribed, especially for recurrent aphthous ulcers (RAUs). The patient rinses for 2 minutes and swallows the syrup, thus obtaining both topical and systemic therapy. Minocycline swish/swallow and chlorhexidine mouthwashes may also be used. A regimen of IV acyclovir (Zovirax) is prescribed for immunocompromised patients who contract herpes simplex stomatitis. Patients with healthy immune systems may be given acyclovir in oral or topical. Fungal infections like yeast, nystatin (Mycostatin) oral suspension swish/swallow is most commonly prescribed. Ice pop troches (lozenges) of the antifungal preparation allow the drug to slowly dissolve, and the cold provides an analgesic effect. Topical triamcinolone in benzocaine (Kenalog in 1102Orabase) and oral dexamethasone elixir used as a swish/expectorate preparation are commonly used for stomatitis, especially RAU. May be prescribed as second-line therapy include:
• Topical amlexanox (Aphthasol)
• Topical granulocyte-macrophage colony-stimulating factor (GM-CSF)
• Thalidomide
Over-the-counter (OTC) benzocaine anesthetics (e.g., Orabase, Anbesol) and camphor phenol (Campho-Phenique) can also control pain. Viscous lidocaine may also be prescribed to use as a gargle or mouthwash. "Magic mouthwash," a mixture of lidocaine, Benadryl, Maalox, Carafate, glucocorticoids, and other ingredients, is also commonly prescribed for those with oral pain due to cancer treatments. Cool or cold liquids can be very soothing, whereas hard, spicy, salty, and acidic foods or fluids can further irritate the ulcers. Include foods high in protein and vitamin C to promote healing, including scrambled eggs, bananas, custards, puddings, and ice cream, unless the patient has lactose intolerance.
Leukoplakia presents as slowly developing changes in the oral mucous membranes causing thickened, white, firmly attached patches that cannot easily be scraped off. These patches appear slightly raised and sharply rounded. Most of these lesions are benign. Lesions on the lips or tongue are more likely to progress to cancer. Leukoplakia results from mechanical factors that cause long-term oral mucous membrane irritation, such as poorly fitting dentures, chronic cheek nibbling, or broken or poorly repaired teeth. In addition, oral hairy leukoplakia (OHL) can be found in patients with human immune deficiency virus (HIV) infection. The Joint Commission (TJC) Core Measures TOB-1 requires asking about tobacco use, because tobacco products (smoked, dipped, or chewed) have also been implicated in the development of leukoplakia, sometimes referred to as "smoker's patch." Leukoplakia cannot be removed by scraping. OHL is associated with Epstein-Barr virus (EBV) and can be an early manifestation of HIV infection. When associated with HIV infection, the appearance of OHL is highly correlated with progression from HIV infection to acquired immune deficiency syndrome (AIDS).
Erythroplakia appear as red, velvety mucosal lesions on the surface of the oral mucosa. There are more malignant changes in erythroplakia than in leukoplakia. These lesions should be regarded with suspicion and analyzed by biopsy. Erythroplakia is most commonly found on the floor of the mouth, tongue, palate, and mandibular mucosa.
90% of oral cancers are squamous cell carcinomas that begin on the surface of the epithelium. Alterations in the thickness of the lining of the epithelium develop, resulting in atrophy. These tumors usually grow slowly. Mucosal erythroplasia is the earliest sign of oral carcinoma. Oral lesions that appear as red, raised, eroded areas are suspicious for cancer. A lesion that does not heal within 2 weeks or a lump or thickening in the cheek is a symptom that warrants further assessment. The major risk factors in its development are increasing age(>40), tobacco use, and alcohol use. Occupations such as textile workers, plumbers, and coal and metal workers, mainly due to prolonged exposure to polycyclic aromatic hydrocarbons (PAHs). People with periodontal (gum) disease in which mandibular (jaw) bone loss has occurred are especially at risk for cancer of the mouth. Additional factors, such as sun exposure, poor nutrition habits, poor oral hygiene, and infection with the human papilloma virus (HPV16) may also contribute. Oral cancer associated with HPV appears in the tonsillar area or along the base of the tongue in younger people. Oral cavity inspection combined with neck palpation is recommended yearly to aid in early detection.
Basal cell carcinoma of the mouth occurs primarily on the lips. The lesion is asymptomatic and resembles a raised scab. With time, it evolves into a characteristic ulcer with a raised, pearly border. Basal cell carcinomas do not metastasize (spread) but can aggressively involve the skin of the face. The major risk factor for this type of cancer is excessive sunlight exposure.
Kaposi's sarcoma is a malignant lesion in blood vessels, appearing as a raised, purple nodule or plaque, which is usually painless. In the mouth, the hard palate is the most common site of Kaposi's sarcoma, but it can be found also on the gums, tongue, or tonsils. It is most often associated with AIDS.
Implement interventions to manage the patient's airway by increasing air exchange, removing secretions, and preventing aspiration as needed. Assess for dyspnea. Assess the quality, rate, and depth of respirations. Auscultate the lungs for adventitious sounds, such as wheezes caused by aspiration. Listen for stridor caused by partial airway obstruction. Promote deep breathing to help produce an effective cough to mobilize the patient's secretions. To promote gas exchange, place the patient in a semi-Fowler's or high-Fowler's position. If the patient is able to swallow and gag reflexes are intact, it is beneficial to encourage fluids to liquefy secretions for easier removal. Chest physiotherapy also increases air exchange as well as promotes effective coughing. If available, collaborate with the respiratory therapist. se oral suction equipment with a dental tip or a tonsil tip (Yankauer catheter) to remove secretions that obstruct the airway. Teach the patient and family to use the catheters. The patient may receive steroids to reduce inflammation. Antibiotics may be prescribed if infection is present. A cool mist supplied by a face tent may assist with oxygen transport and control of edema. It is important to work with the patient to establish an oral hygiene routine. Perform oral hygiene every 2 hours for ulcerated lesions, infection, or in the immediate postoperative period. A soft-bristled toothbrush is preferred. If the platelet count falls below 40,000/mm3, switch the patient to an ultrasoft "chemobrush." The use of "Toothettes" or a disposable foam brush is discouraged because these products may not adequately control bacteremia-promoting plaque and may further dry the oral mucosa. Lubricant can be applied to moisten the lips and oral mucosa. Avoid using commercial mouthwashes and lemon-glycerin swabs. Commercial mouthwashes contain alcohol, and lemon-glycerin swabs are acidic. Encourage frequent rinsing of the mouth with sodium bicarbonate solution or warm saline. Radiation therapy for oral cancers can be given by external beam or interstitial implantation to reduce the size of the tumor before surgery. External-beam radiation passes through the skin or mucous membrane to the tumor site. Implantation of radioactive substances (interstitial radiation therapy or brachytherapy) either to boost the dosage or to deliver a radiation dose close to the tumor bed. This form of implant therapy can be curative in early-stage .
Place patients on radiation transmission precautions while the materials are active or in place. Patients need to be placed in a private room with lead-lined walls or moveable panels. When permitted, visitors may stay only 30 minutes or less each day and must sit or stand away from the patient. Pregnant women and children younger than 18 years should not be permitted to visit. Teach the patient undergoing chemotherapy and family members about the side effects of these agents. Give antiemetics as prescribed, and provide other comfort measures as needed.
One of these GFs is called epidermal growth factor (EGF), which has been associated with oral cancers. Newer drugs that can target and block EGF receptors (EGF-R) are being tested, and more than a dozen have been approved, including cetuximab (Erbitux), erlotinib (Tarceva), and panitumumab (Vectibix).
The patient may have a temporary or permanent tracheostomy, requiring intensive nursing care to promote airway clearance. In addition, care must be taken to protect the surgical incision site from mechanical damage and infection. Nursing interventions to relieve pain or discomfort and promote nutrition. Ensure that the predetermined method of communication is available. When the patient has an adequate airway and can effectively clear secretions by coughing, the tracheostomy tube may be removed. When the tube is removed, an airtight dressing is placed over the site and the tracheostomy incision heals without the need for sutures. Collaborate with the speech-language pathologist if speech is altered. Protect the incision site to avoid infection. Provide gentle mouth care for cleaning away thick secretions and stimulating the flow of saliva. Give oral care at least every 4 hours in the early postoperative phase. The presence of unusual odors from the mouth can indicate infection. Take care to avoid disruption of the suture line during oral hygiene. Elevate the head of the bed to assist in decreasing edema by gravity. If skin grafting was done, inspect the donor site (generally on the anterior thigh) every 8 hours for bleeding or signs of infection. The desired outcome of drug therapy during this period is relief of pain while allowing the patient to function at an optimal level. IV morphine is usually the initial pain medication given with acetaminophen or ibuprofen to decrease inflammation. Tylox or Percocet (oxycodone plus acetaminophen) may be used for systemic relief of moderate pain after the IV morphine is discontinued.
Patients who have undergone extensive resections of the oral cavity remain on NPO status for several days. Nasogastric feeding or total parenteral nutrition may be needed until oral nutrition can begin. Encourage the patient to perform swallowing exercises. Collaborate with the speech-language pathologist to assist with swallowing techniques. Thickened fluids may be needed to prevent aspiration.
Before hospital discharge, teach the patient and family about drug therapy, nutrition therapies, any treatments (e.g., tracheostomy care, suture line care, dressing changes), and early symptoms of infection. Alterations in taste and dysphagia make maintaining adequate nutrition a challenge for the oral cancer patient. Taste sensation may begin to return several weeks after the completion of treatment. Some types of chemotherapy can also affect the patient's taste. Sometimes the loss of taste is permanent. Changes in taste include dislike of meat, such as beef or pork, and metallic tastes in the mouth. Teach patients to add seasonings to foods, to use gravies or sauces to make foods more palatable, and to use high-protein foods such as cheeses, milk, eggs, puddings, and legumes in place of meat. Instruct patients with dysphagia in swallowing exercises. Recommend thickened liquids. Liquid dietary supplements are usually recommended at this time. If bleeding or stomatitis is present, recommend soft foods to prevent further injury to the mucous membranes. Teach the patient or family members to inspect the oral cavity daily for areas of redness, which can indicate the onset of stomatitis. Meticulous oral hygiene should be continued at home, especially with adjuvant chemotherapy or radiation. Reinforce the oral hygiene routine, emphasizing the need for frequent mouth rinsing to reduce the number of microorganisms and to maintain adequate hydration. The patient should use a chemobrush (an extra-soft type of toothbrush), rinse the chemobrush with hydrogen peroxide and water or with a diluted bleach solution after each use, and change chemobrushes weekly. The brush may also be cleaned in a dishwasher. The resulting xerostomia (dry mouth) causes the inability to eat dry foods and may be permanent. Teach the patient regarding the use of saliva substitutes.
Skin reactions are also a common side effect of radiation. Instruct the patient to avoid sun exposure, to avoid perfumed lotions and powders, and to cleanse the face and neck area with a gentle nondeodorant soap. Teach male patients to use an electric razor for shaving and to avoid alcohol-based aftershave lotions.
Relatively rare. Initially, malignant tumors present as slow-growing, painless masses. Involvement of the facial nerve results in facial weakness or paralysis (partial or total) on the affected side.
Collect information about any prior radiation exposure, because radiation to the head and neck areas is associated with the occurrence of salivary gland tumors. Salivary gland tumors present as localized, firm masses. Submandibular and minor salivary gland tumors may be tender or painful. Tumor invasion of the hypoglossal nerve causes impaired movement of the tongue, and a loss of sensation can follow. Pay particular attention to assessment of the facial nerve because of its proximity to the salivary glands. Assess the patient's ability to:
• Wrinkle the brow
• Raise the eyebrows
• Squeeze and hold the eyes shut while you gently pull upwards on the eyebrows and cheeks beneath the orbit to check for symmetry
• Wrinkle the nose
• Pucker the lips
• Puff out the cheeks
• Grimace or smile
Be aware of any asymmetry when the patient performs these motions. The treatment of choice for both benign and malignant tumors of the salivary glands is surgical excision. However, radiation therapy is often used for salivary gland cancers that are large, have recurred, show evidence of residual disease after excision, or are highly malignant. Patients who have undergone parotidectomy (surgical removal of the parotid glands) or submandibular gland surgery are at risk for weakness or loss of function of the facial nerve because the nerve courses directly through the gland. Facial nerve repair with grafting can be done at the time of surgery. A combination of surgery followed by radiation is common for advanced disease.