Oral Care - CBM and Oxford

Question 1

How common and important are oral problems in cancer patients?

Answer 1

• 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

Question 2

Oral hygiene

Answer 2

• 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,

Question 3

Xerostomia - etiology

Answer 3

• 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

Question 4

Xerostomia - managment

Answer 4

• 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

Question 5

Stomatitis - Mucositis

Answer 5

• 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

Question 6

Oral candidiasis - Causes

Answer 6

• 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)

Question 7

Oral Candidiasis : Clinical Manifestations

Answer 7

• 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

Question 8

Oral candidiasis : treatment

Answer 8

• 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

Question 9

Management of oral pain

Answer 9

• identify causes
• reduction of factors
• optimization of hygiene
• treatment of infection
• topical analgesics or systemic analgesics
• Dietitian support for optimization of nutrition

Question 10

Topical Anesthetics and mucosal coating agents

Answer 10

• 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

Question 11

Other common oral infections

Answer 11

• 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

Question 12

List oral symptoms

Answer 12

• 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

Question 13

Taste disturbance

Answer 13

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

Question 14

Xerostomia vs salivary gland dysfunction - physical exam

Answer 14

• 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

Question 15

Sialorrhea and Drooling and Tenacious saliva

Answer 15

• 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